Healthcare Provider Details

I. General information

NPI: 1811503121
Provider Name (Legal Business Name): MARY CARBONNEAU CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2020
Last Update Date: 09/22/2020
Certification Date: 09/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

38 MCELWAIN ST
MERRIMACK NH
03054-3663
US

IV. Provider business mailing address

BOOTHBY THERAPY SERVICES 806 NORTH MAIN STREET
LACONIA NH
03246
US

V. Phone/Fax

Practice location:
  • Phone: 603-424-6204
  • Fax: 603-424-6230
Mailing address:
  • Phone: 603-524-9090
  • Fax: 603-524-1497

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number1901
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: