Provider Demographics
NPI:1457850489
Name:GILLILAND, CARISSA ELIZABETH (MED, BCBA, LBA)
Entity Type:Individual
Prefix:MRS
First Name:CARISSA
Middle Name:ELIZABETH
Last Name:GILLILAND
Suffix:
Gender:F
Credentials:MED, BCBA, LBA
Other - Prefix:MISS
Other - First Name:CARISSA
Other - Middle Name:ELIZABETH
Other - Last Name:THARP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4170 N 108TH AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85037-5469
Mailing Address - Country:US
Mailing Address - Phone:480-751-1957
Mailing Address - Fax:
Practice Address - Street 1:2400 W DUNLAP AVE STE 100
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85021-2813
Practice Address - Country:US
Practice Address - Phone:602-325-2485
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-05
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBEH-000496103K00000X, 103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst