Provider Demographics
NPI:1881204246
Name:CAMPBELL, CARISSA NICOLE (OTD, OTR/L)
Entity type:Individual
Prefix:
First Name:CARISSA
Middle Name:NICOLE
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:CARISSA
Other - Middle Name:NICOLE
Other - Last Name:ANDERSON/BAUGHMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3453 RIVERSTONE WAY APT 1336
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:IN
Mailing Address - Zip Code:47201-8183
Mailing Address - Country:US
Mailing Address - Phone:812-569-3310
Mailing Address - Fax:
Practice Address - Street 1:118 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-3323
Practice Address - Country:US
Practice Address - Phone:317-863-0714
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-31
Last Update Date:2024-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INRBT-19-95273106S00000X
IN31008556A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician