Provider Demographics
NPI:1598406407
Name:BAYNO, CARISSA PIASIDAD
Entity Type:Individual
Prefix:
First Name:CARISSA
Middle Name:PIASIDAD
Last Name:BAYNO
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 1:405 W TORRANCE AVE APT 4
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:IL
Mailing Address - Zip Code:61764-2761
Mailing Address - Country:US
Mailing Address - Phone:646-858-8334
Mailing Address - Fax:
Practice Address - Street 1:405 W TORRANCE AVE APT 4
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:IL
Practice Address - Zip Code:61764-2761
Practice Address - Country:US
Practice Address - Phone:646-858-8334
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-05
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.023332225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
3031400004OtherCIGNA PPO