Provider Demographics
NPI:1265684054
Name:GARRISON, TISA RAE (LCSW)
Entity Type:Individual
Prefix:
First Name:TISA
Middle Name:RAE
Last Name:GARRISON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 CARRIAGE CT
Mailing Address - Street 2:
Mailing Address - City:NEVADA
Mailing Address - State:MO
Mailing Address - Zip Code:64772-3079
Mailing Address - Country:US
Mailing Address - Phone:760-985-0982
Mailing Address - Fax:
Practice Address - Street 1:1425 1/2 LETTS AVE
Practice Address - Street 2:
Practice Address - City:CORCORAN
Practice Address - State:CA
Practice Address - Zip Code:93212-2717
Practice Address - Country:US
Practice Address - Phone:559-762-7044
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-13
Last Update Date:2022-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 211761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical