Provider Demographics
NPI:1588120752
Name:FARRIS, CAROLYN STACEY (TLPC)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:STACEY
Last Name:FARRIS
Suffix:
Gender:F
Credentials:TLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1223
Mailing Address - Street 2:
Mailing Address - City:GREAT BEND
Mailing Address - State:KS
Mailing Address - Zip Code:67530-1223
Mailing Address - Country:US
Mailing Address - Phone:620-796-2206
Mailing Address - Fax:
Practice Address - Street 1:809 S PATTON RD
Practice Address - Street 2:
Practice Address - City:GREAT BEND
Practice Address - State:KS
Practice Address - Zip Code:67530-4625
Practice Address - Country:US
Practice Address - Phone:
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-13
Last Update Date:2019-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS3375101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health