Healthcare Provider Details

I. General information

NPI: 1982046397
Provider Name (Legal Business Name): LAURA JEAN CARROLL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2013
Last Update Date: 11/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

299 12TH ST STE A
MARINA CA
93933-6003
US

IV. Provider business mailing address

299 12TH ST STE A
MARINA CA
93933-6003
US

V. Phone/Fax

Practice location:
  • Phone: 831-647-7711
  • Fax:
Mailing address:
  • Phone: 831-784-2150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberASW62449
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: