Provider Demographics
NPI:1104869551
Name:BENNETT, CARISSA DARLENE (AUD)
Entity type:Individual
Prefix:
First Name:CARISSA
Middle Name:DARLENE
Last Name:BENNETT
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11645 WILSHIRE BLVD
Mailing Address - Street 2:SUITE # 600
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-1708
Mailing Address - Country:US
Mailing Address - Phone:310-477-5558
Mailing Address - Fax:310-477-7281
Practice Address - Street 1:11645 WILSHIRE BLVD
Practice Address - Street 2:SUITE # 600
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-1708
Practice Address - Country:US
Practice Address - Phone:310-477-5558
Practice Address - Fax:310-477-7281
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2009-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAU759174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAUD0007590Medicaid
CAAUD0007590Medicaid
CAAUD759Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER