Healthcare Provider Details

I. General information

NPI: 1033514807
Provider Name (Legal Business Name): BRENDA M. CARROLL LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2014
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7402 YORK ROAD SUITE 300
TOWSON MD
21204-7522
US

IV. Provider business mailing address

7402 YORK ROAD SUITE 300
TOWSON MD
21204-7522
US

V. Phone/Fax

Practice location:
  • Phone: 443-529-6623
  • Fax:
Mailing address:
  • Phone: 443-529-6623
  • Fax: 410-825-6038

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLC5859
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCA2422
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number37LC00204000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: