Basic Information
| Provider Information | |||||||||
| NPI: | 1851451330 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHAN | ||||||||
| FirstName: | MARIE CLAIRE | ||||||||
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| Credential: | SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 147 MILK ST | ||||||||
| Address2: | PROVIDER ENROLLMENT - 9TH FLOOR | ||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021094806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6175598053 | ||||||||
| FaxNumber: | 6174213487 | ||||||||
| Practice Location | |||||||||
| Address1: | 1250 HANCOCK ST | ||||||||
| Address2: | |||||||||
| City: | QUINCY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021694339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6177740600 | ||||||||
| FaxNumber: | 6177740211 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2006 | ||||||||
| LastUpdateDate: | 06/17/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 6923 | MA | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 0039869 | 01 | MA | NEIGHBORHOOD HEALTH | OTHER | 908317 | 01 | MA | TUFTS | OTHER |