Healthcare Provider Details

I. General information

NPI: 1578070926
Provider Name (Legal Business Name): STORMIE LEE CARROLL MA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STORMIE LEE KERBY BS

II. Dates (important events)

Enumeration Date: 01/08/2018
Last Update Date: 01/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9330 59TH AVE SW
LAKEWOOD WA
98499-2858
US

IV. Provider business mailing address

PO BOX 34703
SEATTLE WA
98124-1703
US

V. Phone/Fax

Practice location:
  • Phone: 253-620-5015
  • Fax:
Mailing address:
  • Phone: 206-764-0502
  • Fax: 206-764-0516

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMC60922300
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: