Healthcare Provider Details

I. General information

NPI: 1134627383
Provider Name (Legal Business Name): KACI CARROLL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2018
Last Update Date: 09/09/2022
Certification Date: 09/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4487 FORBES BLVD # 4485
LANHAM MD
20706-4354
US

IV. Provider business mailing address

4487 FORBES BLVD # 4485
LANHAM MD
20706-4354
US

V. Phone/Fax

Practice location:
  • Phone: 301-429-2900
  • Fax:
Mailing address:
  • Phone: 301-429-2900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-19-40382
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-16-25979
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: