Provider Demographics
NPI:1982083598
Name:CARROLL, DERRICK
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:
Last Name:CARROLL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3150 W SAHARA AVE STE B22
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89102-6002
Mailing Address - Country:US
Mailing Address - Phone:702-489-2889
Mailing Address - Fax:702-489-8264
Practice Address - Street 1:3150 W SAHARA AVE STE B22
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-6002
Practice Address - Country:US
Practice Address - Phone:702-489-2889
Practice Address - Fax:702-489-8264
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-28
Last Update Date:2015-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical