Provider Demographics
NPI:1861827529
Name:ORTMAN, CARISSA SWANSTROM
Entity Type:Individual
Prefix:MS
First Name:CARISSA
Middle Name:SWANSTROM
Last Name:ORTMAN
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 1:30700 MARIMOOR ST
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48025-5046
Mailing Address - Country:US
Mailing Address - Phone:319-321-8954
Mailing Address - Fax:
Practice Address - Street 1:18 NEWTON ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301
Practice Address - Country:US
Practice Address - Phone:508-583-6498
Practice Address - Fax:508-583-3775
Is Sole Proprietor?:No
Enumeration Date:2013-09-12
Last Update Date:2018-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1821159880OtherAGENCY NPI