Provider Demographics
NPI:1952902298
Name:WHITLATCH, KARISSA LYNN (LAC)
Entity Type:Individual
Prefix:
First Name:KARISSA
Middle Name:LYNN
Last Name:WHITLATCH
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3651 E BASELINE RD STE E120
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234-2689
Mailing Address - Country:US
Mailing Address - Phone:909-262-6616
Mailing Address - Fax:
Practice Address - Street 1:3651 E BASELINE RD STE E120
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-2689
Practice Address - Country:US
Practice Address - Phone:909-262-6616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-03
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-16801101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor