MEDICARE: MARY N. CARROLL MS, LPCC, RPT

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	101YM0800X	Mental Health Counselor	NM 4094	NM

General Provider Information

NPI Number	:	1679674212
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY N. CARROLL MS, LPCC, RPT

Provider Business Mailing Address
First Line	:	3508 ELDER MEADOWS DR NE
Second Line	:
City	:	RIO RANCHO
State	:	NM
Zip	:	87144-0562
Country	:	US
Telephone Number	:	505-268-3064
Fax Number	:	505-268-9390

Provider Business Practice Location Address
First Line	:	1400 BARBARA LOOP SE STE D
Second Line	:
City	:	RIO RANCHO
State	:	NM
Zip	:	87124-1088
Country	:	US
Telephone Number	:	505-268-3064
Fax Number	:	505-268-9390

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

Provider Enumeration Date	:	09/26/2006
Last Update Date	:	07/08/2007

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