Basic Information
| Provider Information | |||||||||
| NPI: | 1154703833 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARROLL | ||||||||
| FirstName: | TISHINA | ||||||||
| MiddleName: | MAXINE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCSWA, MSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KALER | ||||||||
| OtherFirstName: | TISHINA | ||||||||
| OtherMiddleName: | MAXINE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LCSWA, MSW | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1 HOSPITAL RD | ||||||||
| Address2: | CALLER BOX C-268 | ||||||||
| City: | CHEROKEE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287199253 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8284979163 | ||||||||
| FaxNumber: | 8284971723 | ||||||||
| Practice Location | |||||||||
| Address1: | 375 SEQUOYAH TRL | ||||||||
| Address2: | |||||||||
| City: | CHEROKEE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8284976892 | ||||||||
| FaxNumber: | 8284976977 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2015 | ||||||||
| LastUpdateDate: | 07/21/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | P009637 | NC | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | C010844 | NC | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 1154703833 | 05 | NC | MEDICAID | 19CCS | 01 | NC | BCBS | OTHER |