Provider Demographics
NPI:1134498728
Name:CARROLL, KEYUNA S (LMT)
Entity Type:Individual
Prefix:
First Name:KEYUNA
Middle Name:S
Last Name:CARROLL
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5035 WILLIS AVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75206-6406
Mailing Address - Country:US
Mailing Address - Phone:469-658-9116
Mailing Address - Fax:
Practice Address - Street 1:5035 WILLIS AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75206-6406
Practice Address - Country:US
Practice Address - Phone:469-658-9116
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-28
Last Update Date:2011-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX113362225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX113362OtherTEXAS DEPARTMENT OF STATE HEALTH SERVICES