Provider Demographics
NPI:1346649688
Name:CARROLL, HEATHER (COTA)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:CARROLL
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:
Other - Last Name:WARRELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA
Mailing Address - Street 1:19839 DICE ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46614-5513
Mailing Address - Country:US
Mailing Address - Phone:574-217-2213
Mailing Address - Fax:
Practice Address - Street 1:430 E CLEVELAND RD
Practice Address - Street 2:
Practice Address - City:GRANGER
Practice Address - State:IN
Practice Address - Zip Code:46530-5624
Practice Address - Country:US
Practice Address - Phone:574-271-3305
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-21
Last Update Date:2014-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN32001597AOtherCOTA