Provider Demographics
NPI:1225659527
Name:CARROLL, THERESIA
Entity Type:Individual
Prefix:
First Name:THERESIA
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 1:17746 OAK PARK AVE
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60477-3936
Mailing Address - Country:US
Mailing Address - Phone:708-444-1012
Mailing Address - Fax:708-614-7831
Practice Address - Street 1:1236 ASHLAND AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60411-2544
Practice Address - Country:US
Practice Address - Phone:708-444-1012
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-28
Last Update Date:2020-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator