Provider Demographics
NPI:1538578547
Name:CARROLL, LACIE (LMSW)
Entity type:Individual
Prefix:MRS
First Name:LACIE
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 1:2812 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:TX
Mailing Address - Zip Code:75551-3040
Mailing Address - Country:US
Mailing Address - Phone:731-313-0093
Mailing Address - Fax:
Practice Address - Street 1:2812 W MAIN ST
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:TX
Practice Address - Zip Code:75551-3040
Practice Address - Country:US
Practice Address - Phone:731-313-0093
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-05
Last Update Date:2014-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX58612104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker