Provider Demographics
NPI:1760253132
Name:ALLEN, CHARISSA KIM
Entity Type:Individual
Prefix:
First Name:CHARISSA
Middle Name:KIM
Last Name:ALLEN
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 1:1633 E 4TH ST STE 120
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92701-5143
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1633 E 4TH ST STE 120
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701-5143
Practice Address - Country:US
Practice Address - Phone:714-558-9266
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-12
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist