Healthcare Provider Details

I. General information

NPI: 1144178989
Provider Name (Legal Business Name): MICHELE M CARROLL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2026
Last Update Date: 03/18/2026
Certification Date: 03/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 BEECH ST BLDG 7
NORMAL IL
61761-1493
US

IV. Provider business mailing address

902 W OLIVE ST
BLOOMINGTON IL
61701-4963
US

V. Phone/Fax

Practice location:
  • Phone: 309-287-5381
  • Fax:
Mailing address:
  • Phone: 309-287-5381
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: MICHELE M CARROLL
Title or Position: OWNER
Credential:
Phone: 309-287-5381