Provider Demographics
NPI:1366928756
Name:WILSON, CARMEN SHAW (AUD)
Entity type:Individual
Prefix:
First Name:CARMEN
Middle Name:SHAW
Last Name:WILSON
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:CARMEN
Other - Middle Name:
Other - Last Name:SHAW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:330 BROOKLINE AVE BLDG GROUP
Mailing Address - Street 2:SHAPIRO BUILDING, GROUND FLOOR, SUITE SCG63
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-5491
Mailing Address - Country:US
Mailing Address - Phone:617-632-7500
Mailing Address - Fax:
Practice Address - Street 1:330 BROOKLINE AVENUE
Practice Address - Street 2:SHAPIRO BUILDING, GROUND FLOOR, SUITE SCG63
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215
Practice Address - Country:US
Practice Address - Phone:617-632-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-18
Last Update Date:2022-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4731231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110171698AMedicaid