Healthcare Provider Details

I. General information

NPI: 1346595030
Provider Name (Legal Business Name): JOHN M CAROLL LPCC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2012
Last Update Date: 08/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

814 MADISON AVE
COVINGTON KY
41011
US

IV. Provider business mailing address

3754 HERITAGE POINTE BLVD
MASON OH
45040-7628
US

V. Phone/Fax

Practice location:
  • Phone: 855-591-0092
  • Fax: 606-329-1530
Mailing address:
  • Phone: 606-923-9042
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number1384
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: