Provider Demographics
NPI:1942670732
Name:CARROLL, VANESSA
Entity Type:Individual
Prefix:
First Name:VANESSA
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 1:12501 N STATE ROAD 49
Mailing Address - Street 2:
Mailing Address - City:WHEATFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46392-8986
Mailing Address - Country:US
Mailing Address - Phone:219-956-3125
Mailing Address - Fax:
Practice Address - Street 1:12501 N STATE ROAD 49
Practice Address - Street 2:
Practice Address - City:WHEATFIELD
Practice Address - State:IN
Practice Address - Zip Code:46392-8986
Practice Address - Country:US
Practice Address - Phone:219-956-3125
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-06
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health