=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629633417
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LUANA CARROLL LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/07/2019
-----------------------------------------------------
Last Update Date | 12/30/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 68 BISHOP ST
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04103-2681
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-423-7622
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 4
-----------------------------------------------------
City | BUXTON
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04093-0004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-423-7622
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | LC17742
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------