Provider Demographics
NPI:1063899599
Name:PREUDHOMME, KARISSA
Entity type:Individual
Prefix:
First Name:KARISSA
Middle Name:
Last Name:PREUDHOMME
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 1:58 NORTH AVE APT 102
Mailing Address - Street 2:
Mailing Address - City:NATICK
Mailing Address - State:MA
Mailing Address - Zip Code:01760-3569
Mailing Address - Country:US
Mailing Address - Phone:336-978-4443
Mailing Address - Fax:
Practice Address - Street 1:735 TIVOLI CIR
Practice Address - Street 2:APT 201
Practice Address - City:DEERFIELD BEACH
Practice Address - State:FL
Practice Address - Zip Code:33441-8112
Practice Address - Country:US
Practice Address - Phone:336-978-4443
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-05
Last Update Date:2022-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL15-11178106S00000X
222Q00000X
MA1-20-43664103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist