Provider Demographics
NPI:1417041500
Name:CARROLL, MARY C (MSSW, LICSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:C
Last Name:CARROLL
Suffix:
Gender:F
Credentials:MSSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 RADIO DR
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-8409
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1000 RADIO DR
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-8409
Practice Address - Country:US
Practice Address - Phone:651-365-8209
Practice Address - Fax:651-739-0272
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN95241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNHP19174OtherHEALTHPARTNERS
MN108544OtherUCARE
MN62-49483OtherUBH
MN494S0CAOtherBCBS