Provider Demographics
NPI:1316396682
Name:GUNATHILAKA, CARISSA BROOKE (LPC)
Entity Type:Individual
Prefix:
First Name:CARISSA
Middle Name:BROOKE
Last Name:GUNATHILAKA
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 WOODBINE PL
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75601-2912
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:701 E MARSHALL AVE
Practice Address - Street 2:SUITE 310
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75601-5659
Practice Address - Country:US
Practice Address - Phone:903-234-9200
Practice Address - Fax:903-232-1590
Is Sole Proprietor?:No
Enumeration Date:2016-06-08
Last Update Date:2016-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX72933101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional