Provider Demographics
NPI:1336903673
Name:CARROLL, KENNETH SHAUN (LMHC)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:SHAUN
Last Name:CARROLL
Suffix:
Gender:M
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:368 VETERANS MEMORIAL HWY STE 3
Mailing Address - Street 2:
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725-4322
Mailing Address - Country:US
Mailing Address - Phone:631-533-0315
Mailing Address - Fax:
Practice Address - Street 1:368 VETERANS MEMORIAL HWY STE 3
Practice Address - Street 2:
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725-4322
Practice Address - Country:US
Practice Address - Phone:631-533-0315
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-07
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014227101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty