Healthcare Provider Details

I. General information

NPI: 1932132552
Provider Name (Legal Business Name): TRESHA CARROLL DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2006
Last Update Date: 10/30/2023
Certification Date: 10/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

784 14TH AVE
LONGVIEW WA
98632-2315
US

IV. Provider business mailing address

1057 12TH AVE
LONGVIEW WA
98632-2509
US

V. Phone/Fax

Practice location:
  • Phone: 360-703-6400
  • Fax: 360-353-3611
Mailing address:
  • Phone: 360-636-3892
  • Fax: 360-414-1342

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOP00001788
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: