Provider Demographics
NPI:1952549891
Name:CARROLL, JOHN BRADLEY (PHD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:BRADLEY
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:PO BOX 2689
Mailing Address - Street 2:2311 E. STADIUM BLVD
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48106-2689
Mailing Address - Country:US
Mailing Address - Phone:734-761-9835
Mailing Address - Fax:248-855-3866
Practice Address - Street 1:31500 W 13 MILE RD
Practice Address - Street 2:#111
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-2164
Practice Address - Country:US
Practice Address - Phone:248-855-9220
Practice Address - Fax:248-855-3866
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-30
Last Update Date:2009-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103G00000X, 103TC2200X
MI6301007077103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI68-0-F3-3086-0OtherBCBS OF MICHIGAN