Provider Demographics
NPI:1982913380
Name:UNDERWOOD, CAROL A (MA, SLP)
Entity type:Individual
Prefix:MRS
First Name:CAROL
Middle Name:A
Last Name:UNDERWOOD
Suffix:
Gender:F
Credentials:MA, SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:149 DAYTON AVE
Mailing Address - Street 2:
Mailing Address - City:MANORVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11949-2005
Mailing Address - Country:US
Mailing Address - Phone:631-878-4441
Mailing Address - Fax:
Practice Address - Street 1:149 DAYTON AVE
Practice Address - Street 2:
Practice Address - City:MANORVILLE
Practice Address - State:NY
Practice Address - Zip Code:11949-2005
Practice Address - Country:US
Practice Address - Phone:631-878-4441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-02
Last Update Date:2010-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02558794Medicaid
NY113498292OtherEIN #