Provider Demographics
NPI:1043763154
Name:HARVEY, CARLISSA
Entity Type:Individual
Prefix:
First Name:CARLISSA
Middle Name:
Last Name:HARVEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3310 MERAMEC ST
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63118-4311
Mailing Address - Country:US
Mailing Address - Phone:314-749-0152
Mailing Address - Fax:844-316-0208
Practice Address - Street 1:3310 MERAMEC ST
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63118-4311
Practice Address - Country:US
Practice Address - Phone:314-749-0152
Practice Address - Fax:844-316-0208
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-26
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
253Z00000X, 374U00000X
MOLC9814754251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No253Z00000XAgenciesIn Home Supportive Care
No374U00000XNursing Service Related ProvidersHome Health Aide