Provider Demographics
NPI:1720150436
Name:CARROLL, SERVIO A (NCSP, LPC)
Entity type:Individual
Prefix:MR
First Name:SERVIO
Middle Name:A
Last Name:CARROLL
Suffix:
Gender:M
Credentials:NCSP, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:511 AIRPORT RD
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-5801
Mailing Address - Country:US
Mailing Address - Phone:307-672-6251
Mailing Address - Fax:307-672-6251
Practice Address - Street 1:108 S THURMOND ST
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-4145
Practice Address - Country:US
Practice Address - Phone:307-752-6251
Practice Address - Fax:307-672-6251
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYLPC- NO. 12101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional