Provider Demographics
NPI:1114257417
Name:STEPAN, CARISSA ELIZABETH (PSYD, LP)
Entity Type:Individual
Prefix:MRS
First Name:CARISSA
Middle Name:ELIZABETH
Last Name:STEPAN
Suffix:
Gender:F
Credentials:PSYD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:588 101ST AVE N
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34108-3201
Mailing Address - Country:US
Mailing Address - Phone:651-439-2059
Mailing Address - Fax:888-675-8262
Practice Address - Street 1:1751 TOWER DR W STE 200
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082-7596
Practice Address - Country:US
Practice Address - Phone:651-439-2059
Practice Address - Fax:888-675-8262
Is Sole Proprietor?:No
Enumeration Date:2010-01-08
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5209103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical