Basic Information
| Provider Information | |||||||||
| NPI: | 1972793248 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CAROTA | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | POLUHA | ||||||||
| OtherFirstName: | JENNIFER | ||||||||
| OtherMiddleName: | L | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 593 EDDY ST | ||||||||
| Address2: | GEORGE CLINIC | ||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029034923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014443201 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 593 EDDY ST | ||||||||
| Address2: | GEORGE CLINIC | ||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029034923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014443201 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2007 | ||||||||
| LastUpdateDate: | 12/31/2007 | ||||||||
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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 | SP00159 | RI | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | SP00159-P | 01 | RI | LICENSE | OTHER |