Healthcare Provider Details

I. General information

NPI: 1508401134
Provider Name (Legal Business Name): MARY SHANNON CARROLL AU.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2019
Last Update Date: 11/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 BERGEN STREET E-1680
NEWARK NJ
07103
US

IV. Provider business mailing address

1028 LAUREL TRL
MARTINSVILLE NJ
08836-2211
US

V. Phone/Fax

Practice location:
  • Phone: 973-972-1017
  • Fax:
Mailing address:
  • Phone: 908-872-0653
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number41YA00105600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: