Provider Demographics
NPI:1184794984
Name:SHELL, CARISSA (BA)
Entity type:Individual
Prefix:
First Name:CARISSA
Middle Name:
Last Name:SHELL
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 S FORT THOMAS AVE
Mailing Address - Street 2:
Mailing Address - City:FORT THOMAS
Mailing Address - State:KY
Mailing Address - Zip Code:41075-2421
Mailing Address - Country:US
Mailing Address - Phone:859-781-5586
Mailing Address - Fax:
Practice Address - Street 1:1201 S FORT THOMAS AVE
Practice Address - Street 2:
Practice Address - City:FORT THOMAS
Practice Address - State:KY
Practice Address - Zip Code:41075-2421
Practice Address - Country:US
Practice Address - Phone:859-781-5586
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY184607OtherMEDICARE GROUP NUMBER