Provider Demographics
NPI:1841052255
Name:SUSAN CARROLL
Entity type:Organization
Organization Name:SUSAN CARROLL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:CARROLL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-398-7752
Mailing Address - Street 1:372 MERIDIAN ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02128-5123
Mailing Address - Country:US
Mailing Address - Phone:617-398-7752
Mailing Address - Fax:857-264-5086
Practice Address - Street 1:360 W BOYLSTON ST
Practice Address - Street 2:
Practice Address - City:WEST BOYLSTON
Practice Address - State:MA
Practice Address - Zip Code:01583-2365
Practice Address - Country:US
Practice Address - Phone:617-398-7752
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-30
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered