Provider Demographics
NPI:1023519717
Name:CARROLL, KYLIE NICOLE (LPC)
Entity type:Individual
Prefix:MISS
First Name:KYLIE
Middle Name:NICOLE
Last Name:CARROLL
Suffix:
Gender:F
Credentials:LPC
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 11818
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72917-1818
Mailing Address - Country:US
Mailing Address - Phone:479-452-6650
Mailing Address - Fax:479-452-5847
Practice Address - Street 1:5401 ROGERS AVE STE 201
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-3763
Practice Address - Country:US
Practice Address - Phone:479-242-4560
Practice Address - Fax:479-242-4561
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-27
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA1802014101YM0800X
ARP2101136101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health