MEDICARE: THERESA LYNN CARROLL PCC-S

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	E0003512	OH

General Provider Information

NPI Number	:	1821262254
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THERESA LYNN CARROLL PCC-S

Provider Business Mailing Address
First Line	:	PO BOX 9432
Second Line	:
City	:	CANTON
State	:	OH
Zip	:	44711-9432
Country	:	US
Telephone Number	:	330-491-1351
Fax Number	:	330-491-9720

Provider Business Practice Location Address
First Line	:	720 19TH ST NE
Second Line	:
City	:	CANTON
State	:	OH
Zip	:	44714-2213
Country	:	US
Telephone Number	:	330-491-1351
Fax Number	:	330-491-9720

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/16/2008
Last Update Date	:	04/16/2008

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