Provider Demographics
NPI:1588008122
Name:CARROLL, MICHELE M (LCSW)
Entity Type:Individual
Prefix:MS
First Name:MICHELE
Middle Name:M
Last Name:CARROLL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:902 W OLIVE ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-4963
Mailing Address - Country:US
Mailing Address - Phone:309-287-5381
Mailing Address - Fax:
Practice Address - Street 1:808 S ELDORADO RD STE 102
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-6075
Practice Address - Country:US
Practice Address - Phone:309-706-3190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-25
Last Update Date:2020-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0136911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical