Healthcare Provider Details

I. General information

NPI: 1225354376
Provider Name (Legal Business Name): DALLAS RAY CARROLL CDP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2010
Last Update Date: 04/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

260 FLYAWAY RD
CASTLE ROCK WA
98611-9128
US

IV. Provider business mailing address

PO BOX 2562
LONGVIEW WA
98632-8607
US

V. Phone/Fax

Practice location:
  • Phone: 360-431-1929
  • Fax:
Mailing address:
  • Phone: 360-431-1929
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCP60112671
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: