Provider Demographics
NPI:1568199305
Name:CARROLL, CASEY AMANDA
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:AMANDA
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 1:405 GREY LAG LN
Mailing Address - Street 2:
Mailing Address - City:SWANSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:28584-8560
Mailing Address - Country:US
Mailing Address - Phone:502-322-5441
Mailing Address - Fax:
Practice Address - Street 1:5248 OLDE TOWNE RD
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23188-1986
Practice Address - Country:US
Practice Address - Phone:757-603-4603
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-02
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09060126541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty