Provider Demographics
NPI:1841257037
Name:CARROLL, JOHN EDWIN (LCMHCS)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:EDWIN
Last Name:CARROLL
Suffix:
Gender:M
Credentials:LCMHCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:233 SHORELINE DR
Mailing Address - Street 2:
Mailing Address - City:NEW BERN
Mailing Address - State:NC
Mailing Address - Zip Code:28562-9557
Mailing Address - Country:US
Mailing Address - Phone:252-633-1770
Mailing Address - Fax:252-633-1005
Practice Address - Street 1:1425 S GLENBURNIE RD STE 5
Practice Address - Street 2:
Practice Address - City:NEW BERN
Practice Address - State:NC
Practice Address - Zip Code:28562-2610
Practice Address - Country:US
Practice Address - Phone:252-675-3620
Practice Address - Fax:252-633-1005
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-01
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3874101Y00000X
NCS3874101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC139X5OtherBC
NC6102827Medicaid