Provider Demographics
NPI:1477677664
Name:RUBOTTOM, CARISSA DEE
Entity type:Individual
Prefix:
First Name:CARISSA
Middle Name:DEE
Last Name:RUBOTTOM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CARISSA
Other - Middle Name:DEE
Other - Last Name:MYERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3075 P RD
Mailing Address - Street 2:
Mailing Address - City:WOODSTON
Mailing Address - State:KS
Mailing Address - Zip Code:67675-9057
Mailing Address - Country:US
Mailing Address - Phone:785-434-6335
Mailing Address - Fax:
Practice Address - Street 1:208 E 7TH ST
Practice Address - Street 2:
Practice Address - City:HAYS
Practice Address - State:KS
Practice Address - Zip Code:67601-4199
Practice Address - Country:US
Practice Address - Phone:785-628-2871
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2025-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE13093101YM0800X
WY1093225100000X
KS11-07480225100000X
KS04535101YM0800X
NE2500225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist