Provider Demographics
NPI:1962648352
Name:KLEVENS-THOMAS, CARISSA LEIGH (PHD)
Entity Type:Individual
Prefix:DR
First Name:CARISSA
Middle Name:LEIGH
Last Name:KLEVENS-THOMAS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:351 E TEMPLE ST
Mailing Address - Street 2:116B
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90012-3328
Mailing Address - Country:US
Mailing Address - Phone:213-253-2677
Mailing Address - Fax:213-253-5046
Practice Address - Street 1:351 E TEMPLE ST
Practice Address - Street 2:116B
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90012-3328
Practice Address - Country:US
Practice Address - Phone:213-253-2677
Practice Address - Fax:213-253-5046
Is Sole Proprietor?:No
Enumeration Date:2009-01-06
Last Update Date:2011-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22967103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling