Provider Demographics
NPI:1245501295
Name:PONCELET, CARISSA
Entity type:Individual
Prefix:
First Name:CARISSA
Middle Name:
Last Name:PONCELET
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4300 E WALKER WAY
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57103-1148
Mailing Address - Country:US
Mailing Address - Phone:605-480-0641
Mailing Address - Fax:
Practice Address - Street 1:706 EAGLE RUN
Practice Address - Street 2:
Practice Address - City:DELL RAPIDS
Practice Address - State:SD
Practice Address - Zip Code:57022-2142
Practice Address - Country:US
Practice Address - Phone:605-428-5851
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-23
Last Update Date:2012-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA000815224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant