Basic Information
| Provider Information | |||||||||
| NPI: | 1194880666 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CARROLL | ||||||||
| FirstName: | MICHELLE | ||||||||
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| Credential: | LICSW, BCD | ||||||||
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| Mailing Information | |||||||||
| Address1: | BROOKE ARMY MEDICAL CENTER, | ||||||||
| Address2: | 3551 ROGER BROOKE DRIVE, | ||||||||
| City: | FORT SAM HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78234 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2105399582 | ||||||||
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| Practice Location | |||||||||
| Address1: | KIMBROUGH AMBULATORY CARE CENTER | ||||||||
| Address2: | 2480 LLEWELLYN AVE. | ||||||||
| City: | FT MEADE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 20755 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016778270 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/26/2006 | ||||||||
| LastUpdateDate: | 01/10/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.