Provider Demographics
NPI:1174028237
Name:HACK, CARISSA (DPT, ATC)
Entity Type:Individual
Prefix:
First Name:CARISSA
Middle Name:
Last Name:HACK
Suffix:
Gender:F
Credentials:DPT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1319 DELANE AVE APT 6
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211-2539
Mailing Address - Country:US
Mailing Address - Phone:571-239-3610
Mailing Address - Fax:
Practice Address - Street 1:449 N WENDOVER RD # B
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-1064
Practice Address - Country:US
Practice Address - Phone:704-366-7723
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-29
Last Update Date:2022-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP21321225100000X
PA2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist