Provider Demographics
NPI:1154703833
Name:CARROLL, TISHINA MAXINE (LCSWA, MSW)
Entity type:Individual
Prefix:
First Name:TISHINA
Middle Name:MAXINE
Last Name:CARROLL
Suffix:
Gender:F
Credentials:LCSWA, MSW
Other - Prefix:
Other - First Name:TISHINA
Other - Middle Name:MAXINE
Other - Last Name:KALER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSWA, MSW
Mailing Address - Street 1:1 HOSPITAL RD
Mailing Address - Street 2:CALLER BOX C-268
Mailing Address - City:CHEROKEE
Mailing Address - State:NC
Mailing Address - Zip Code:28719-9253
Mailing Address - Country:US
Mailing Address - Phone:828-497-9163
Mailing Address - Fax:828-497-1723
Practice Address - Street 1:375 SEQUOYAH TRL
Practice Address - Street 2:
Practice Address - City:CHEROKEE
Practice Address - State:NC
Practice Address - Zip Code:28719
Practice Address - Country:US
Practice Address - Phone:828-497-6892
Practice Address - Fax:828-497-6977
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-18
Last Update Date:2017-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0096371041C0700X
NCC0108441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1154703833Medicaid
NC19CCSOtherBCBS