Provider Demographics
NPI:1689396335
Name:MARTIN, CARISSA ROSE
Entity Type:Individual
Prefix:
First Name:CARISSA
Middle Name:ROSE
Last Name:MARTIN
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 1:323 E POINTE LN APT G17
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-1970
Mailing Address - Country:US
Mailing Address - Phone:810-625-3756
Mailing Address - Fax:
Practice Address - Street 1:323 E POINTE LN APT G17
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-1970
Practice Address - Country:US
Practice Address - Phone:810-625-3756
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-19
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6851115010101YA0400X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)