Provider Demographics
NPI:1730803560
Name:CARROLL, KATRINA (LMSW)
Entity type:Individual
Prefix:
First Name:KATRINA
Middle Name:
Last Name:CARROLL
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 W 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:TRUTH OR CONSEQUENCES
Mailing Address - State:NM
Mailing Address - Zip Code:87901-2204
Mailing Address - Country:US
Mailing Address - Phone:575-740-7645
Mailing Address - Fax:
Practice Address - Street 1:411 W 5TH AVE
Practice Address - Street 2:
Practice Address - City:TRUTH OR CONSEQUENCES
Practice Address - State:NM
Practice Address - Zip Code:87901-2204
Practice Address - Country:US
Practice Address - Phone:575-740-7645
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-26
Last Update Date:2024-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NMSWB-2024-0303104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program