Provider Demographics
NPI:1932613213
Name:BREDE, CARISSA LYNN (LMHC)
Entity Type:Individual
Prefix:
First Name:CARISSA
Middle Name:LYNN
Last Name:BREDE
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:463142 STATE ROAD 200
Mailing Address - Street 2:
Mailing Address - City:YULEE
Mailing Address - State:FL
Mailing Address - Zip Code:32097-5554
Mailing Address - Country:US
Mailing Address - Phone:904-225-8280
Mailing Address - Fax:904-225-8232
Practice Address - Street 1:463142 STATE ROAD 200
Practice Address - Street 2:
Practice Address - City:YULEE
Practice Address - State:FL
Practice Address - Zip Code:32097-5554
Practice Address - Country:US
Practice Address - Phone:904-225-8280
Practice Address - Fax:904-225-8232
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-26
Last Update Date:2020-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH17642101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMH17642OtherLICENSED MENTAL HEALTH COUNSELOR