MEDICARE: CRYSTAL MARIE CARROLL

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	1041S0200X	School Social Worker		OK

General Provider Information

NPI Number	:	1982555694
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CRYSTAL MARIE CARROLL

Provider Business Mailing Address
First Line	:	3614 W NORTH AVE
Second Line	:
City	:	PONCA CITY
State	:	OK
Zip	:	74601-7726
Country	:	US
Telephone Number	:	209-405-1740
Fax Number	:

Provider Business Practice Location Address
First Line	:	3614 W NORTH AVE
Second Line	:
City	:	PONCA CITY
State	:	OK
Zip	:	74601-7726
Country	:	US
Telephone Number	:	209-405-1740
Fax Number	:

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

Provider Enumeration Date	:	02/07/2026
Last Update Date	:	02/07/2026

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