Provider Demographics
NPI:1942791991
Name:CANTELUPE, CARISSA MARIE
Entity Type:Individual
Prefix:MISS
First Name:CARISSA
Middle Name:MARIE
Last Name:CANTELUPE
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:CARISSA
Other - Middle Name:MARIE
Other - Last Name:COLCHIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1 ELIZABETH PL STE D
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45417-3445
Mailing Address - Country:US
Mailing Address - Phone:937-222-2233
Mailing Address - Fax:
Practice Address - Street 1:1 ELIZABETH PL STE D
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45417-3445
Practice Address - Country:US
Practice Address - Phone:937-222-2233
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-25
Last Update Date:2018-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH140320101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)