Provider Demographics
NPI:1477812964
Name:CARROLL, STEPHANIE JEANNE (LCSW, CAC III)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:JEANNE
Last Name:CARROLL
Suffix:
Gender:F
Credentials:LCSW, CAC III
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:928 12TH ST
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80631-4024
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:928 12TH ST
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80631-4024
Practice Address - Country:US
Practice Address - Phone:970-352-1056
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-03
Last Update Date:2012-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO6678101YA0400X
CO12441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)