Healthcare Provider Details

I. General information

NPI: 1952563868
Provider Name (Legal Business Name): TAMARA CARROLL ACSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2008
Last Update Date: 07/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

66 HURLBUT ST
PASADENA CA
91105-4025
US

IV. Provider business mailing address

2326 NAVARRO AVE
ALTADENA CA
91001-5616
US

V. Phone/Fax

Practice location:
  • Phone: 626-441-4221
  • Fax:
Mailing address:
  • Phone: 626-398-0555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number17805
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: