Provider Demographics
NPI:1972002236
Name:CARROLL, JOHN JOSEPH III (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:JOSEPH
Last Name:CARROLL
Suffix:III
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1290
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:CA
Mailing Address - Zip Code:90294-1290
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:323-978-5849
Practice Address - Street 1:15235 BURBANK BLVD STE A2
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91411-3555
Practice Address - Country:US
Practice Address - Phone:858-883-3277
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-01
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY29750103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical