Provider Demographics
NPI:1912373556
Name:MARTIN, CARISSA (PSY D)
Entity Type:Individual
Prefix:
First Name:CARISSA
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PSY D
Other - Prefix:
Other - First Name:CARISSA
Other - Middle Name:
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSY D
Mailing Address - Street 1:2309 W BROADWAY APT 113
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-1274
Mailing Address - Country:US
Mailing Address - Phone:502-472-4499
Mailing Address - Fax:
Practice Address - Street 1:600 E 5TH ST
Practice Address - Street 2:
Practice Address - City:FULTON
Practice Address - State:MO
Practice Address - Zip Code:65251-1753
Practice Address - Country:US
Practice Address - Phone:573-592-3355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-18
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020004458103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical