Provider Demographics
NPI:1356919344
Name:PROVOST, KARISSA ANN
Entity type:Individual
Prefix:
First Name:KARISSA
Middle Name:ANN
Last Name:PROVOST
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 1:26330 DIAMOND PL STE 130
Mailing Address - Street 2:
Mailing Address - City:SANTA CLARITA
Mailing Address - State:CA
Mailing Address - Zip Code:91350-5819
Mailing Address - Country:US
Mailing Address - Phone:818-501-3512
Mailing Address - Fax:
Practice Address - Street 1:26330 DIAMOND PL STE 130
Practice Address - Street 2:
Practice Address - City:SANTA CLARITA
Practice Address - State:CA
Practice Address - Zip Code:91350-5819
Practice Address - Country:US
Practice Address - Phone:818-501-3512
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-15
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53366106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist