Provider Demographics
NPI:1093324097
Name:CAIBAL, CARISSA
Entity Type:Individual
Prefix:
First Name:CARISSA
Middle Name:
Last Name:CAIBAL
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 1:8610 GRAND AVE APT 3C
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-4307
Mailing Address - Country:US
Mailing Address - Phone:718-679-3928
Mailing Address - Fax:
Practice Address - Street 1:1400 OLD COUNTRY RD STE C-103N
Practice Address - Street 2:
Practice Address - City:WESTBURY
Practice Address - State:NY
Practice Address - Zip Code:11590-5156
Practice Address - Country:US
Practice Address - Phone:516-806-6969
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-24
Last Update Date:2020-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1409694202174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist