Provider Demographics
NPI:1568125383
Name:PROVOST, CARISSA (LMHC-P)
Entity Type:Individual
Prefix:
First Name:CARISSA
Middle Name:
Last Name:PROVOST
Suffix:
Gender:F
Credentials:LMHC-P
Other - Prefix:
Other - First Name:CARISSA
Other - Middle Name:
Other - Last Name:KENNEDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:PLATTSBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12901-3420
Mailing Address - Country:US
Mailing Address - Phone:518-825-1555
Mailing Address - Fax:
Practice Address - Street 1:8 BROAD ST
Practice Address - Street 2:
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12901-3420
Practice Address - Country:US
Practice Address - Phone:518-825-1555
Practice Address - Fax:518-825-1550
Is Sole Proprietor?:No
Enumeration Date:2021-10-19
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013715101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health