Provider Demographics
NPI:1962565697
Name:CARROLL, MARY THEODORA (PHD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:THEODORA
Last Name:CARROLL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:173 VENICE PALMS BLVD
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34292-2447
Mailing Address - Country:US
Mailing Address - Phone:941-412-3947
Mailing Address - Fax:941-412-3957
Practice Address - Street 1:405 JULIA PL
Practice Address - Street 2:SARASOTA
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34236-6915
Practice Address - Country:US
Practice Address - Phone:941-412-3947
Practice Address - Fax:941-412-3957
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH0002776101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health