Provider Demographics
NPI:1255918694
Name:CHAREST, MARCIE FAY (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:MARCIE
Middle Name:FAY
Last Name:CHAREST
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 SNIPSIC LAKE RD
Mailing Address - Street 2:
Mailing Address - City:ELLINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06029-3521
Mailing Address - Country:US
Mailing Address - Phone:860-930-4207
Mailing Address - Fax:
Practice Address - Street 1:31 SNIPSIC LAKE RD
Practice Address - Street 2:
Practice Address - City:ELLINGTON
Practice Address - State:CT
Practice Address - Zip Code:06029-3521
Practice Address - Country:US
Practice Address - Phone:860-930-4207
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-24
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002424235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist