Provider Demographics
NPI:1831868595
Name:PELLERIN, CARISSA KIMBERLY (SUBSTANCE ABUSE COUN)
Entity type:Individual
Prefix:
First Name:CARISSA
Middle Name:KIMBERLY
Last Name:PELLERIN
Suffix:
Gender:F
Credentials:SUBSTANCE ABUSE COUN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23520 STILLWATER PL
Mailing Address - Street 2:
Mailing Address - City:SANTA CLARITA
Mailing Address - State:CA
Mailing Address - Zip Code:91321-3555
Mailing Address - Country:US
Mailing Address - Phone:818-240-8843
Mailing Address - Fax:818-240-8885
Practice Address - Street 1:4544 SAN FERNANDO RD
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-1987
Practice Address - Country:US
Practice Address - Phone:818-240-8843
Practice Address - Fax:818-240-8885
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-07
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAF7857329101YA0400X
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)