Provider Demographics
NPI:1508052986
Name:DOUGLAS, CARISSA MARIE (PSYD)
Entity Type:Individual
Prefix:
First Name:CARISSA
Middle Name:MARIE
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41197 GOLDEN GATE CIR STE 206
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562-6999
Mailing Address - Country:US
Mailing Address - Phone:951-394-3227
Mailing Address - Fax:
Practice Address - Street 1:41197 GOLDEN GATE CIR STE 206
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562-6999
Practice Address - Country:US
Practice Address - Phone:951-394-3227
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-19
Last Update Date:2021-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32327103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical