Basic Information
| Provider Information | |||||||||
| NPI: | 1518117761 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CARROLL COUNSELING CENTER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1380 PROGRESS WAY | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | ELDERSBURG | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217846464 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105495181 | ||||||||
| FaxNumber: | 4105495182 | ||||||||
| Practice Location | |||||||||
| Address1: | 1380 PROGRESS WAY | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | ELDERSBURG | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217846464 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105495181 | ||||||||
| FaxNumber: | 4105495182 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/24/2008 | ||||||||
| LastUpdateDate: | 10/18/2022 | ||||||||
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| AuthorizedOfficialLastName: | RICHELSON | ||||||||
| AuthorizedOfficialFirstName: | ELLIOTT | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2527337374 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 10/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TP0016X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Prescribing (Medical) |
ID Information
| ID | Type | State | Issuer | Description | 836102900 | 05 | MD | MEDICAID |