Provider Demographics
NPI:1972269975
Name:VAN MIERLO, CARISSA RAE
Entity Type:Individual
Prefix:
First Name:CARISSA
Middle Name:RAE
Last Name:VAN MIERLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CARISSA
Other - Middle Name:RAE
Other - Last Name:TENNEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2 DAYLILY
Mailing Address - Street 2:
Mailing Address - City:RANCHO SANTA MARGARITA
Mailing Address - State:CA
Mailing Address - Zip Code:92688-1442
Mailing Address - Country:US
Mailing Address - Phone:949-290-1079
Mailing Address - Fax:
Practice Address - Street 1:23961 CALLE DE LA MAGDALENA STE 119
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-3616
Practice Address - Country:US
Practice Address - Phone:949-837-5111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-14
Last Update Date:2021-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant