Provider Demographics
NPI:1639459399
Name:CARISSA BOKELBERG LLC PSYD
Entity Type:Organization
Organization Name:CARISSA BOKELBERG LLC PSYD
Other - Org Name:CARISSA L BOKELBERG, PSY.D.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CARISSA
Authorized Official - Middle Name:L
Authorized Official - Last Name:BOKELBERG
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:504-377-7779
Mailing Address - Street 1:3114 PALMYRA ST
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70119-6220
Mailing Address - Country:US
Mailing Address - Phone:504-377-7779
Mailing Address - Fax:
Practice Address - Street 1:3909 BIENVILLE ST
Practice Address - Street 2:SUITE 102
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70119-5151
Practice Address - Country:US
Practice Address - Phone:504-535-4372
Practice Address - Fax:504-273-1479
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-25
Last Update Date:2012-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1048103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1307424Medicaid