Provider Demographics
NPI:1508340100
Name:CARROLL, ADDIE LOIS
Entity Type:Individual
Prefix:MRS
First Name:ADDIE
Middle Name:LOIS
Last Name:CARROLL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9422 DUKE DR
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72204-4312
Mailing Address - Country:US
Mailing Address - Phone:501-227-7523
Mailing Address - Fax:
Practice Address - Street 1:6900 N HILLS BLVD
Practice Address - Street 2:
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72116-5423
Practice Address - Country:US
Practice Address - Phone:501-834-0217
Practice Address - Fax:501-833-0957
Is Sole Proprietor?:No
Enumeration Date:2018-09-19
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR1124083118Medicaid