Healthcare Provider Details

I. General information

NPI: 1679674212
Provider Name (Legal Business Name): MARY N. CARROLL MS, LPCC, RPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 BARBARA LOOP SE STE D
RIO RANCHO NM
87124-1088
US

IV. Provider business mailing address

3508 ELDER MEADOWS DR NE
RIO RANCHO NM
87144-0562
US

V. Phone/Fax

Practice location:
  • Phone: 505-268-3064
  • Fax: 505-268-9390
Mailing address:
  • Phone: 505-268-3064
  • Fax: 505-268-9390

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberNM 4094
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: