Provider Demographics
NPI:1679674212
Name:CARROLL, MARY N (MS, LPCC, RPT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:N
Last Name:CARROLL
Suffix:
Gender:F
Credentials:MS, LPCC, RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3508 ELDER MEADOWS DR NE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87144-0562
Mailing Address - Country:US
Mailing Address - Phone:505-268-3064
Mailing Address - Fax:505-268-9390
Practice Address - Street 1:1400 BARBARA LOOP SE STE D
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-1088
Practice Address - Country:US
Practice Address - Phone:505-268-3064
Practice Address - Fax:505-268-9390
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMNM 4094101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health