Provider Demographics
NPI:1568960771
Name:BLUTH, CARISSA (COTA)
Entity Type:Individual
Prefix:MRS
First Name:CARISSA
Middle Name:
Last Name:BLUTH
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1927 KIRKPATRICK LOOP
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96818-3702
Mailing Address - Country:US
Mailing Address - Phone:209-912-8511
Mailing Address - Fax:
Practice Address - Street 1:2230 LILIHA ST
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96817-1646
Practice Address - Country:US
Practice Address - Phone:808-547-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-23
Last Update Date:2018-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX37826451OtherNPI REQUIRED BY EMPLOYEER