Provider Demographics
NPI:1962021212
Name:CARROLL, THEODORE L (PHD, LMHC, NCC)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:L
Last Name:CARROLL
Suffix:
Gender:M
Credentials:PHD, LMHC, NCC
Other - Prefix:DR
Other - First Name:TED
Other - Middle Name:L
Other - Last Name:CARROLL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD, LMHC, NCC
Mailing Address - Street 1:603 KNIGHT ST STE D
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99352-3800
Mailing Address - Country:US
Mailing Address - Phone:509-870-7853
Mailing Address - Fax:509-943-2129
Practice Address - Street 1:603 KNIGHT ST STE D
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99352-3800
Practice Address - Country:US
Practice Address - Phone:509-870-7853
Practice Address - Fax:509-943-2129
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-15
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH61050462101Y00000X
WAMG60947452106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMG60947452OtherLICENSING CREDENTIALS
WALH61050462OtherLICENSING CREDENTIALS