Provider Demographics
NPI:1346564309
Name:CARROLL, CYNTHIA M (ITFS, MED)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:M
Last Name:CARROLL
Suffix:
Gender:F
Credentials:ITFS, MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1708A OWEN DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-3419
Mailing Address - Country:US
Mailing Address - Phone:910-425-6282
Mailing Address - Fax:910-425-6554
Practice Address - Street 1:1708A OWEN DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3419
Practice Address - Country:US
Practice Address - Phone:910-425-6282
Practice Address - Fax:910-425-6554
Is Sole Proprietor?:No
Enumeration Date:2010-03-19
Last Update Date:2022-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8300047K222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8300047KMedicaid