Provider Demographics
NPI:1922584028
Name:FRAISER, CAROL SULLIVAN (LMSW)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:SULLIVAN
Last Name:FRAISER
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 CARROLL AVE
Mailing Address - Street 2:
Mailing Address - City:BAY ST LOUIS
Mailing Address - State:MS
Mailing Address - Zip Code:39520-3515
Mailing Address - Country:US
Mailing Address - Phone:601-214-1308
Mailing Address - Fax:
Practice Address - Street 1:819 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:BAY ST LOUIS
Practice Address - State:MS
Practice Address - Zip Code:39520-3913
Practice Address - Country:US
Practice Address - Phone:228-467-1881
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-12
Last Update Date:2018-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSM9097104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker