Provider Demographics
NPI:1417056060
Name:CARROLL, MARIANNE ROBERTS (MA LADC)
Entity Type:Individual
Prefix:
First Name:MARIANNE
Middle Name:ROBERTS
Last Name:CARROLL
Suffix:
Gender:F
Credentials:MA LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:387 TUCKIE RD
Mailing Address - Street 2:D
Mailing Address - City:NORTH WINDHAM
Mailing Address - State:CT
Mailing Address - Zip Code:06256-1355
Mailing Address - Country:US
Mailing Address - Phone:860-423-4279
Mailing Address - Fax:860-423-4284
Practice Address - Street 1:387 TUCKIE RD
Practice Address - Street 2:D
Practice Address - City:NORTH WINDHAM
Practice Address - State:CT
Practice Address - Zip Code:06256-1355
Practice Address - Country:US
Practice Address - Phone:860-423-4279
Practice Address - Fax:860-423-4284
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2014-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000055101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004255007Medicaid
CT199589OtherMHN
P2633664OtherOXFORD
165927OtherVALUE OPTIONS
CT300000055CT01OtherANTHEM