Provider Demographics
NPI:1457984460
Name:NIEMERG, CARISSA WELTON
Entity Type:Individual
Prefix:MRS
First Name:CARISSA
Middle Name:WELTON
Last Name:NIEMERG
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:CARISSA
Other - Middle Name:WELTON
Other - Last Name:GOOSTREE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:14535 N AMBER LN
Mailing Address - Street 2:
Mailing Address - City:EFFINGHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62401-4340
Mailing Address - Country:US
Mailing Address - Phone:618-322-6918
Mailing Address - Fax:
Practice Address - Street 1:14535 N AMBER LN
Practice Address - Street 2:
Practice Address - City:EFFINGHAM
Practice Address - State:IL
Practice Address - Zip Code:62401-4340
Practice Address - Country:US
Practice Address - Phone:618-322-6918
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-18
Last Update Date:2020-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental TherapistGroup - Single Specialty