Provider Demographics
NPI:1588766059
Name:CARROLL, TRISTY LYNN (SLP)
Entity type:Individual
Prefix:MRS
First Name:TRISTY
Middle Name:LYNN
Last Name:CARROLL
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:TRISTY
Other - Middle Name:LYNN
Other - Last Name:DEANS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 532
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:ND
Mailing Address - Zip Code:58402-0532
Mailing Address - Country:US
Mailing Address - Phone:701-252-6066
Mailing Address - Fax:701-252-6074
Practice Address - Street 1:102 2ND AVE SW STE 215A
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:ND
Practice Address - Zip Code:58401-4104
Practice Address - Country:US
Practice Address - Phone:701-320-6488
Practice Address - Fax:701-252-6074
Is Sole Proprietor?:No
Enumeration Date:2006-09-03
Last Update Date:2021-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND683235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1460115Medicaid
ND54820Medicaid