Provider Demographics
NPI:1114497674
Name:HARDIN, CARISSA MARIE (OTR/L)
Entity Type:Individual
Prefix:
First Name:CARISSA
Middle Name:MARIE
Last Name:HARDIN
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1194 BACA AVE NW
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32907-9404
Mailing Address - Country:US
Mailing Address - Phone:505-402-8414
Mailing Address - Fax:
Practice Address - Street 1:2080 W EAU GALLIE BLVD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-3152
Practice Address - Country:US
Practice Address - Phone:407-694-3603
Practice Address - Fax:321-296-7130
Is Sole Proprietor?:No
Enumeration Date:2018-11-27
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3133224Z00000X
FL25043225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant