Provider Demographics
NPI:1063071983
Name:CARROLL, PATRICIA MARIE
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:MARIE
Last Name:CARROLL
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 1:2424 W WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49203-1236
Mailing Address - Country:US
Mailing Address - Phone:517-205-4001
Mailing Address - Fax:517-787-1286
Practice Address - Street 1:2424 W WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49203-1236
Practice Address - Country:US
Practice Address - Phone:517-205-4001
Practice Address - Fax:517-787-1286
Is Sole Proprietor?:No
Enumeration Date:2019-06-13
Last Update Date:2019-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401009331101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional