Provider Demographics
NPI:1306244272
Name:CARMEN, MIRIL
Entity type:Individual
Prefix:
First Name:MIRIL
Middle Name:
Last Name:CARMEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 COLES WAY
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701-4885
Mailing Address - Country:US
Mailing Address - Phone:646-641-9063
Mailing Address - Fax:732-901-8899
Practice Address - Street 1:3 COLES WAY
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08701-4875
Practice Address - Country:US
Practice Address - Phone:732-874-4374
Practice Address - Fax:732-901-8899
Is Sole Proprietor?:No
Enumeration Date:2014-12-09
Last Update Date:2014-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ41YS00619400235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist