Provider Demographics
NPI:1841311719
Name:CARROLL, ROBERT DAVID (LCSW)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:DAVID
Last Name:CARROLL
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:MR
Other - First Name:ROBERT
Other - Middle Name:DAVID
Other - Last Name:CARROLL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CADC
Mailing Address - Street 1:25 BEDELL ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-1705
Mailing Address - Country:US
Mailing Address - Phone:207-252-8739
Mailing Address - Fax:
Practice Address - Street 1:25 BEDELL ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-1705
Practice Address - Country:US
Practice Address - Phone:207-252-8739
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2011-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMC102911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME002143701Medicare PIN