Provider Demographics
NPI:1538937800
Name:CARROLL, TYHEARIA
Entity type:Individual
Prefix:
First Name:TYHEARIA
Middle Name:
Last Name:CARROLL
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:TYHEARIA
Other - Middle Name:
Other - Last Name:CARROLL-MILLER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3014 EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19121-1813
Mailing Address - Country:US
Mailing Address - Phone:267-600-0943
Mailing Address - Fax:
Practice Address - Street 1:5501 OLD YORK RD STE 1
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19141-3098
Practice Address - Country:US
Practice Address - Phone:215-456-6666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-18
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA11340101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)