Basic Information
| Provider Information | |||||||||
| NPI: | 1225532062 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARROLL | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | DAWN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3855 DC CANEY RIDGE RD | ||||||||
| Address2: | |||||||||
| City: | CLINTWOOD | ||||||||
| State: | VA | ||||||||
| PostalCode: | 242287861 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2763932367 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 220 CLAY DR | ||||||||
| Address2: | |||||||||
| City: | POUNDING MILL | ||||||||
| State: | VA | ||||||||
| PostalCode: | 246374320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2769633606 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2018 | ||||||||
| LastUpdateDate: | 03/19/2018 | ||||||||
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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 | 101YP2500X | 0701007460 | VA | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.