Basic Information
| Provider Information | |||||||||
| NPI: | 1689854309 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MONROE | ||||||||
| FirstName: | CAROLYN | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | BS PSYCHOLOGY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3407 SHAMROCK CT | ||||||||
| Address2: | |||||||||
| City: | GAUTIER | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39553 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2284970690 | ||||||||
| FaxNumber: | 2284971363 | ||||||||
| Practice Location | |||||||||
| Address1: | 3407 SHAMROCK CT | ||||||||
| Address2: | |||||||||
| City: | GAUTIER | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39553 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2284970690 | ||||||||
| FaxNumber: | 2284971363 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2007 | ||||||||
| LastUpdateDate: | 11/09/2007 | ||||||||
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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 | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | 00018214 | 05 | MS | MEDICAID |