Provider Demographics
NPI:1649663485
Name:RONDEAU, CARRISSA (BCBA, LLMSW)
Entity type:Individual
Prefix:
First Name:CARRISSA
Middle Name:
Last Name:RONDEAU
Suffix:
Gender:F
Credentials:BCBA, LLMSW
Other - Prefix:
Other - First Name:CARRISSA
Other - Middle Name:
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BCBA, LMSW
Mailing Address - Street 1:1229 W WASHINGTON ST STE 5
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-3186
Mailing Address - Country:US
Mailing Address - Phone:906-439-5290
Mailing Address - Fax:906-225-6706
Practice Address - Street 1:1229 W WASHINGTON ST STE 5
Practice Address - Street 2:
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-3186
Practice Address - Country:US
Practice Address - Phone:906-439-5290
Practice Address - Fax:906-225-6706
Is Sole Proprietor?:No
Enumeration Date:2015-03-17
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
MI68010954841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst