Healthcare Provider Details

I. General information

NPI: 1609338839
Provider Name (Legal Business Name): DONNA R. CARROLL LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2019
Last Update Date: 09/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 REMINGTON PLZ
RAYMORE MO
64083-8640
US

IV. Provider business mailing address

1800 COMMUNITY
CLINTON MO
64735-8804
US

V. Phone/Fax

Practice location:
  • Phone: 888-403-1071
  • Fax:
Mailing address:
  • Phone: 660-885-8131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number00889
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2005025571
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: