MEDICARE: MARIANNE ROBERTS CARROLL MA LADC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	000055	CT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	199589	OTHER	CT	MHN
3	P2633664	OTHER		OXFORD
4	165927	OTHER		VALUE OPTIONS
5	300000055CT01	OTHER	CT	ANTHEM

General Provider Information

NPI Number	:	1417056060
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIANNE ROBERTS CARROLL MA LADC

Provider Business Mailing Address
First Line	:	387 TUCKIE RD
Second Line	:	D
City	:	NORTH WINDHAM
State	:	CT
Zip	:	06256-1355
Country	:	US
Telephone Number	:	860-423-4279
Fax Number	:	860-423-4284

Provider Business Practice Location Address
First Line	:	387 TUCKIE RD
Second Line	:	D
City	:	NORTH WINDHAM
State	:	CT
Zip	:	06256-1355
Country	:	US
Telephone Number	:	860-423-4279
Fax Number	:	860-423-4284

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/21/2006
Last Update Date	:	10/01/2014

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