Provider Demographics
NPI:1184682957
Name:CAROLLO, JONATHAN (LICSW)
Entity Type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:
Last Name:CAROLLO
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1223 S CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99204-4029
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3919 N MAPLE ST
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99205-1349
Practice Address - Country:US
Practice Address - Phone:509-444-8888
Practice Address - Fax:509-444-7806
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW000063121041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8931692OtherL&I CRIME VIC
WAAB11720Medicare ID - Type UnspecifiedGROUP #
WAQ11298Medicare UPIN