Provider Demographics
NPI:1457380842
Name:MARICLE, CARLTON A (MA CCCA)
Entity Type:Individual
Prefix:
First Name:CARLTON
Middle Name:A
Last Name:MARICLE
Suffix:
Gender:M
Credentials:MA CCCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:97 W GANSEVOORT ST
Mailing Address - Street 2:
Mailing Address - City:LITTLE FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:13365-1348
Mailing Address - Country:US
Mailing Address - Phone:315-823-1874
Mailing Address - Fax:315-823-4893
Practice Address - Street 1:97 W GANSEVOORT ST
Practice Address - Street 2:
Practice Address - City:LITTLE FALLS
Practice Address - State:NY
Practice Address - Zip Code:13365-1348
Practice Address - Country:US
Practice Address - Phone:315-823-1874
Practice Address - Fax:315-823-4893
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000878-1231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01106216Medicaid
NY01106216Medicaid
R88853Medicare UPIN