Provider Demographics
NPI:1346595030
Name:CAROLL, JOHN M (LPCC)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:M
Last Name:CAROLL
Suffix:
Gender:M
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3754 HERITAGE POINTE BLVD
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:OH
Mailing Address - Zip Code:45040-7628
Mailing Address - Country:US
Mailing Address - Phone:606-923-9042
Mailing Address - Fax:
Practice Address - Street 1:814 MADISON AVE
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:KY
Practice Address - Zip Code:41011
Practice Address - Country:US
Practice Address - Phone:855-591-0092
Practice Address - Fax:606-329-1530
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-18
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1384101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY30610026Medicaid