Healthcare Provider Details

I. General information

NPI: 1619086618
Provider Name (Legal Business Name): EDWARD NICHOLAS CARROL PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10701 EAST BLVD
CLEVELAND OH
44106-1702
US

IV. Provider business mailing address

21490 CLAYTHORNE RD
SHAKER HEIGHTS OH
44122-1964
US

V. Phone/Fax

Practice location:
  • Phone: 216-791-3800
  • Fax: 216-707-5905
Mailing address:
  • Phone: 216-791-3800
  • Fax: 216-707-5905

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number3106
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: