Provider Demographics
NPI:1346259140
Name:CARROLL, PATRICK J (LCSW)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:J
Last Name:CARROLL
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:512 IRONWOOD CC DR
Mailing Address - Street 2:
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-5267
Mailing Address - Country:US
Mailing Address - Phone:309-263-5565
Mailing Address - Fax:309-263-9336
Practice Address - Street 1:405 KAYS DR
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-1979
Practice Address - Country:US
Practice Address - Phone:309-888-9979
Practice Address - Fax:309-888-9111
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL87368Medicare ID - Type Unspecified