Provider Demographics
NPI:1770886590
Name:CARROLL, CHARLENE KELLY (AUD)
Entity type:Individual
Prefix:
First Name:CHARLENE
Middle Name:KELLY
Last Name:CARROLL
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 JACQUELINE LN
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02360-4665
Mailing Address - Country:US
Mailing Address - Phone:508-415-3096
Mailing Address - Fax:
Practice Address - Street 1:44 WASHINGTON ST
Practice Address - Street 2:SUITE 102A
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02445-7130
Practice Address - Country:US
Practice Address - Phone:617-731-9988
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-16
Last Update Date:2014-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1008231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist