Basic Information
| Provider Information | |||||||||
| NPI: | 1376674010 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARROLL | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | KELLY | ||||||||
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| Credential: | M.S., M.A., APRN-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 805 WESTMONT DR | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283054555 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104844061 | ||||||||
| FaxNumber: | 9104854069 | ||||||||
| Practice Location | |||||||||
| Address1: | 805 WESTMONT DR | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283054555 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104844061 | ||||||||
| FaxNumber: | 9104854069 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2007 | ||||||||
| LastUpdateDate: | 05/22/2008 | ||||||||
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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 | 101YP2500X | 6455 | NC | N | Behavioral Health & Social Service Providers | Counselor | Professional | 363LP0808X | 200401185 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 6113055 | 05 | NC | MEDICAID |