MEDICARE: MS. LATRICIA DESHUN CARROLL BCBA

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	101YP2500X	Professional Counselor	74760	TX
2	103K00000X	Behavior Analyst	1-13-13139	TX

General Provider Information

NPI Number	:	1417590670
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LATRICIA DESHUN CARROLL BCBA

Provider Business Mailing Address
First Line	:	7108 S KANNER HWY
Second Line	:
City	:	STUART
State	:	FL
Zip	:	34997-7462
Country	:	US
Telephone Number	:	855-832-6727
Fax Number	:	772-675-9100

Provider Business Practice Location Address
First Line	:	3301 N 3RD ST
Second Line	:
City	:	ABILENE
State	:	TX
Zip	:	79603-7054
Country	:	US
Telephone Number	:	855-832-6727
Fax Number	:	772-675-9100

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

Provider Enumeration Date	:	10/21/2019
Last Update Date	:	06/26/2023

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