Provider Demographics
NPI:1033994264
Name:CARROLL, SHANNON
Entity Type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:
Last Name:CARROLL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:583 MCKENDIMEN RD
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08055-9774
Mailing Address - Country:US
Mailing Address - Phone:908-217-3076
Mailing Address - Fax:
Practice Address - Street 1:583 MCKENDIMEN RD
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:NJ
Practice Address - Zip Code:08055-9774
Practice Address - Country:US
Practice Address - Phone:908-217-3076
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-28
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst