Provider Demographics
NPI:1760009955
Name:CARROLL, TAMMY
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:
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 1:3801 LAKE CT
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:IL
Mailing Address - Zip Code:62293-2938
Mailing Address - Country:US
Mailing Address - Phone:573-382-0732
Mailing Address - Fax:
Practice Address - Street 1:3801 LAKE CT
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:IL
Practice Address - Zip Code:62293-2938
Practice Address - Country:US
Practice Address - Phone:573-382-0732
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-03
Last Update Date:2020-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0486259103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool