Provider Demographics
NPI:1396224051
Name:CARROLL, CHARLES (CMHT)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:CARROLL
Suffix:
Gender:M
Credentials:CMHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 WHITE ST
Mailing Address - Street 2:PO BOX 769
Mailing Address - City:MCCOMB
Mailing Address - State:MS
Mailing Address - Zip Code:39648
Mailing Address - Country:US
Mailing Address - Phone:601-249-4214
Mailing Address - Fax:601-249-4234
Practice Address - Street 1:1701 WHITE ST
Practice Address - Street 2:
Practice Address - City:MCCOMB
Practice Address - State:MS
Practice Address - Zip Code:39648
Practice Address - Country:US
Practice Address - Phone:601-249-4214
Practice Address - Fax:601-249-4234
Is Sole Proprietor?:No
Enumeration Date:2018-08-13
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00018209Medicaid