Provider Demographics
NPI:1760415673
Name:CARROLL, REBECCA MARIA (LCSW)
Entity Type:Individual
Prefix:MS
First Name:REBECCA
Middle Name:MARIA
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 1:1485 S SEMORAN BLVD
Mailing Address - Street 2:STE 1454 BLDG #6
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32792-5533
Mailing Address - Country:US
Mailing Address - Phone:407-671-2258
Mailing Address - Fax:407-671-2675
Practice Address - Street 1:1485 S SEMORAN BLVD
Practice Address - Street 2:STE 1454 BLDG #6
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32792-5533
Practice Address - Country:US
Practice Address - Phone:407-671-2258
Practice Address - Fax:407-671-2675
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW26851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ5303ZMedicare ID - Type Unspecified