Provider Demographics
NPI:1598102105
Name:VINSON, CARROLL (MSED SDA)
Entity Type:Individual
Prefix:MS
First Name:CARROLL
Middle Name:
Last Name:VINSON
Suffix:
Gender:F
Credentials:MSED SDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 ADAMS ST APT 3A
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11201-2862
Mailing Address - Country:US
Mailing Address - Phone:917-817-6097
Mailing Address - Fax:
Practice Address - Street 1:116 W 32ND ST
Practice Address - Street 2:8TH FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-3212
Practice Address - Country:US
Practice Address - Phone:212-564-2350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-23
Last Update Date:2013-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY628480951103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst