Provider Demographics
NPI:1982046397
Name:CARROLL, LAURA JEAN
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:JEAN
Last Name:CARROLL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:299 12TH ST STE A
Mailing Address - Street 2:
Mailing Address - City:MARINA
Mailing Address - State:CA
Mailing Address - Zip Code:93933-6003
Mailing Address - Country:US
Mailing Address - Phone:831-784-2150
Mailing Address - Fax:
Practice Address - Street 1:299 12TH ST STE A
Practice Address - Street 2:
Practice Address - City:MARINA
Practice Address - State:CA
Practice Address - Zip Code:93933-6003
Practice Address - Country:US
Practice Address - Phone:831-647-7711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-25
Last Update Date:2016-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW624491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical