=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962565697
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARY THEODORA CARROLL PHD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/17/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 405 JULIA PL SARASOTA
-----------------------------------------------------
City | SARASOTA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34236-6915
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-412-3947
-----------------------------------------------------
Fax | 941-412-3957
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 173 VENICE PALMS BLVD
-----------------------------------------------------
City | VENICE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34292-2447
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-412-3947
-----------------------------------------------------
Fax | 941-412-3957
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | MH0002776
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------