Basic Information
| Provider Information | |||||||||
| NPI: | 1124198270 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARROLL | ||||||||
| FirstName: | LYNN | ||||||||
| MiddleName: | RAE | ||||||||
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| Credential: | LCPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 43 SIS PORTER ROAD | ||||||||
| Address2: | |||||||||
| City: | SEDGWICK | ||||||||
| State: | ME | ||||||||
| PostalCode: | 04676 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2073269179 | ||||||||
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| Practice Location | |||||||||
| Address1: | 415 WATER ST | ||||||||
| Address2: | |||||||||
| City: | ELLSWORTH | ||||||||
| State: | ME | ||||||||
| PostalCode: | 046052116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2076675357 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2006 | ||||||||
| LastUpdateDate: | 01/24/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | LMHC - 0097841 | NM | N | Behavioral Health & Social Service Providers | Counselor | 101YM0800X | CC3486 | ME | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health | 104100000X | LS3891 | ME | N | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 17384265 | 05 | NM | MEDICAID |