Provider Demographics
NPI:1578234787
Name:CARRICO, ALISA MARIE
Entity Type:Individual
Prefix:
First Name:ALISA
Middle Name:MARIE
Last Name:CARRICO
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 1:3400 W STONEGATE BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60005-1068
Mailing Address - Country:US
Mailing Address - Phone:331-241-6485
Mailing Address - Fax:
Practice Address - Street 1:3400 W STONEGATE BLVD STE 101
Practice Address - Street 2:
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60005-1068
Practice Address - Country:US
Practice Address - Phone:331-241-6485
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-27
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician