Healthcare Provider Details

I. General information

NPI: 1700074531
Provider Name (Legal Business Name): MARJORIE ELLEN CARR L.C.S.W
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2007
Last Update Date: 10/05/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5525 E IRLO BRONSON HWY
ST CLOUD FL
34771-8736
US

IV. Provider business mailing address

5525 E BRONSON HWY
ST CLOUD FL
34771
US

V. Phone/Fax

Practice location:
  • Phone: 407-892-1226
  • Fax: 407-892-1226
Mailing address:
  • Phone: 407-892-1226
  • Fax: 407-892-1226

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW2582
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: