Provider Demographics
NPI:1952468787
Name:CARROLL, TIMOTHY KENNELL (PHD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:KENNELL
Last Name:CARROLL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4790 N WINNERS CIR APT A
Mailing Address - Street 2:
Mailing Address - City:PALM SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92264-5833
Mailing Address - Country:US
Mailing Address - Phone:707-479-6048
Mailing Address - Fax:
Practice Address - Street 1:4790 N WINNERS CIR UNIT A
Practice Address - Street 2:
Practice Address - City:PALM SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92264-5868
Practice Address - Country:US
Practice Address - Phone:707-479-6048
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2020-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY15865103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical