Basic Information
| Provider Information | |||||||||
| NPI: | 1205479789 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARROLL | ||||||||
| FirstName: | JERRY | ||||||||
| MiddleName: | MONROE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1022 EVANGELINE RD | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441103151 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2165120995 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1227 ANSEL RD | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441083323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2164210662 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2019 | ||||||||
| LastUpdateDate: | 08/10/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.