Provider Demographics
NPI:1568897288
Name:PALMBERG, CARISSA ANN (MS, LPC, LAC)
Entity Type:Individual
Prefix:
First Name:CARISSA
Middle Name:ANN
Last Name:PALMBERG
Suffix:
Gender:F
Credentials:MS, LPC, LAC
Other - Prefix:
Other - First Name:CARISSA
Other - Middle Name:ANN
Other - Last Name:PETERSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:48261 268TH ST
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:SD
Mailing Address - Zip Code:57005-8501
Mailing Address - Country:US
Mailing Address - Phone:605-951-6267
Mailing Address - Fax:
Practice Address - Street 1:48261 268TH ST
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:SD
Practice Address - Zip Code:57005-8501
Practice Address - Country:US
Practice Address - Phone:605-951-6267
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-12
Last Update Date:2016-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDLPC7276101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor