Basic Information
| Provider Information | |||||||||
| NPI: | 1255469912 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARROLL | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | KATHERINE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1401 SOUTH FEDERAL HIGHWAY | ||||||||
| Address2: | |||||||||
| City: | FORT LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333162619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9547125091 | ||||||||
| FaxNumber: | 9547792316 | ||||||||
| Practice Location | |||||||||
| Address1: | 1401 SOUTH FEDERAL HIGHWAY | ||||||||
| Address2: | |||||||||
| City: | FORT LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333162619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9549439589 | ||||||||
| FaxNumber: | 9549434115 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2007 | ||||||||
| LastUpdateDate: | 02/09/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | SA3241 | FL | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 222Q00000X | SA3241 | FL | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Developmental Therapist |
ID Information
| ID | Type | State | Issuer | Description | 812122200 | 05 | FL | MEDICAID | 88255300 | 05 | FL | MEDICAID | SA3241 | 01 | FL | LISENCE | OTHER |