Provider Demographics
NPI:1710442892
Name:CARRIMON, VALERIE MIRANDA (SAC-IT)
Entity Type:Individual
Prefix:
First Name:VALERIE
Middle Name:MIRANDA
Last Name:CARRIMON
Suffix:
Gender:F
Credentials:SAC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:S237 PINE AVE
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:WI
Mailing Address - Zip Code:54651-7619
Mailing Address - Country:US
Mailing Address - Phone:608-799-4797
Mailing Address - Fax:715-284-3434
Practice Address - Street 1:N6520 LUMBERJACK GUY RD
Practice Address - Street 2:
Practice Address - City:BLACK RIVER FALLS
Practice Address - State:WI
Practice Address - Zip Code:54615-5405
Practice Address - Country:US
Practice Address - Phone:715-284-9851
Practice Address - Fax:715-284-3434
Is Sole Proprietor?:No
Enumeration Date:2019-02-04
Last Update Date:2019-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI18155101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)