Basic Information
| Provider Information | |||||||||
| NPI: | 1255519906 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARROLL | ||||||||
| FirstName: | MARVA | ||||||||
| MiddleName: | |||||||||
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| Credential: | MSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 525 WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142031711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168534424 | ||||||||
| FaxNumber: | 7163322820 | ||||||||
| Practice Location | |||||||||
| Address1: | 359 GRIDER ST | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142153016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168957715 | ||||||||
| FaxNumber: | 7168951544 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/05/2008 | ||||||||
| LastUpdateDate: | 02/05/2008 | ||||||||
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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 | 104100000X | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 00675796 | 05 | NY | MEDICAID |