Provider Demographics
NPI:1265857999
Name:CARROLL, JUDITH LYNN
Entity Type:Individual
Prefix:MISS
First Name:JUDITH
Middle Name:LYNN
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 1:2428 N STOKESBERRY PL
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-5035
Mailing Address - Country:US
Mailing Address - Phone:208-939-3888
Mailing Address - Fax:208-939-5599
Practice Address - Street 1:2428 N STOKESBERRY PL
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-5035
Practice Address - Country:US
Practice Address - Phone:208-939-3888
Practice Address - Fax:208-939-5599
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-05
Last Update Date:2014-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-336481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical