Provider Demographics
NPI:1922632363
Name:WHITE, CARISSA JOYCE (MPS, LADC, MHP)
Entity Type:Individual
Prefix:
First Name:CARISSA
Middle Name:JOYCE
Last Name:WHITE
Suffix:
Gender:F
Credentials:MPS, LADC, MHP
Other - Prefix:
Other - First Name:CARISSA
Other - Middle Name:JOYCE
Other - Last Name:JAHNZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2031 ROWLAND RD
Mailing Address - Street 2:
Mailing Address - City:MORA
Mailing Address - State:MN
Mailing Address - Zip Code:55051-7119
Mailing Address - Country:US
Mailing Address - Phone:320-364-1300
Mailing Address - Fax:651-323-2558
Practice Address - Street 1:2031 ROWLAND RD
Practice Address - Street 2:
Practice Address - City:MORA
Practice Address - State:MN
Practice Address - Zip Code:55051-7119
Practice Address - Country:US
Practice Address - Phone:320-364-1300
Practice Address - Fax:651-323-2558
Is Sole Proprietor?:No
Enumeration Date:2020-02-25
Last Update Date:2020-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN305579101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)