Healthcare Provider Details

I. General information

NPI: 1154106524
Provider Name (Legal Business Name): KATHRYN ELIZABETH CARROLL LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2023
Last Update Date: 11/19/2025
Certification Date: 11/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1211 PORTER WAGONER BLVD
WEST PLAINS MO
65775-1826
US

IV. Provider business mailing address

1211 PORTER WAGONER BLVD
WEST PLAINS MO
65775-1826
US

V. Phone/Fax

Practice location:
  • Phone: 417-257-6762
  • Fax:
Mailing address:
  • Phone: 417-257-6762
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number2023031347
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2025049636
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: