Provider Demographics
NPI:1194166116
Name:PARKER, CARISSA MICHELLE (DPT)
Entity type:Individual
Prefix:
First Name:CARISSA
Middle Name:MICHELLE
Last Name:PARKER
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:CARISSA
Other - Middle Name:MICHELLE
Other - Last Name:WIGAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:4900 S ARROWHEAD DR
Mailing Address - Street 2:STE B
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MO
Mailing Address - Zip Code:64055-6952
Mailing Address - Country:US
Mailing Address - Phone:816-795-6999
Mailing Address - Fax:816-795-3366
Practice Address - Street 1:1254 SE CENTURY DR
Practice Address - Street 2:
Practice Address - City:LEES SUMMIT
Practice Address - State:MO
Practice Address - Zip Code:64081-3286
Practice Address - Country:US
Practice Address - Phone:480-452-5302
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-08
Last Update Date:2019-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO225100000X, 2251X0800X
MO2013023363225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1194166116OtherPHYSICAL THERAPIST
MO1194166116Medicaid