Provider Demographics
NPI:1104694942
Name:HAVINS, KARISSA
Entity type:Individual
Prefix:
First Name:KARISSA
Middle Name:
Last Name:HAVINS
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 1:434 COUNTY ROAD 290
Mailing Address - Street 2:
Mailing Address - City:GARRISON
Mailing Address - State:TX
Mailing Address - Zip Code:75946-5918
Mailing Address - Country:US
Mailing Address - Phone:936-553-9557
Mailing Address - Fax:
Practice Address - Street 1:434 COUNTY ROAD 290
Practice Address - Street 2:
Practice Address - City:GARRISON
Practice Address - State:TX
Practice Address - Zip Code:75946-5918
Practice Address - Country:US
Practice Address - Phone:936-553-9557
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-12
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX210328224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant