Healthcare Provider Details

I. General information

NPI: 1497381610
Provider Name (Legal Business Name): ELIZABETH CARROLL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/19/2020
Last Update Date: 01/06/2025
Certification Date: 01/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 S 36TH AVE
WAUSAU WI
54401-3930
US

IV. Provider business mailing address

630 S 36TH AVE
WAUSAU WI
54401-3930
US

V. Phone/Fax

Practice location:
  • Phone: 855-607-8242
  • Fax: 715-848-0425
Mailing address:
  • Phone: 855-607-8242
  • Fax: 715-848-0425

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC.2103101
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC.2002348-TRNE
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberC.2002348-TRNE
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: