Provider Demographics
NPI:1780034017
Name:CARROLL, FLETCHER JR
Entity Type:Individual
Prefix:
First Name:FLETCHER
Middle Name:
Last Name:CARROLL
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 RYBAR LN
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32164-6445
Mailing Address - Country:US
Mailing Address - Phone:386-316-3004
Mailing Address - Fax:
Practice Address - Street 1:23 RYBAR LN
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32164-6445
Practice Address - Country:US
Practice Address - Phone:386-316-3004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-17
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL018070500Medicaid
FL003553600Medicaid