Provider Demographics
NPI:1720486483
Name:STUCK, CARISSA
Entity Type:Individual
Prefix:
First Name:CARISSA
Middle Name:
Last Name:STUCK
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 1:505 N BRAND BLVD
Mailing Address - Street 2:#1000
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91203-1906
Mailing Address - Country:US
Mailing Address - Phone:818-241-6780
Mailing Address - Fax:818-241-6853
Practice Address - Street 1:3111 N TUSTIN ST
Practice Address - Street 2:#100
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92865-1750
Practice Address - Country:US
Practice Address - Phone:855-295-3276
Practice Address - Fax:818-241-6853
Is Sole Proprietor?:No
Enumeration Date:2014-12-11
Last Update Date:2014-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPE 9554235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARPE 9554OtherSLP