Provider Demographics
NPI:1497539357
Name:MEDULLA, KARISSA CLAIRE
Entity Type:Individual
Prefix:
First Name:KARISSA
Middle Name:CLAIRE
Last Name:MEDULLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26210 HARPER AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48081-2203
Mailing Address - Country:US
Mailing Address - Phone:248-912-2460
Mailing Address - Fax:
Practice Address - Street 1:26210 HARPER AVE
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48081-2203
Practice Address - Country:US
Practice Address - Phone:888-485-8636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-22
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician