Provider Demographics
NPI:1285478073
Name:MACDONALD, KARISSA (CPSS)
Entity type:Individual
Prefix:
First Name:KARISSA
Middle Name:
Last Name:MACDONALD
Suffix:
Gender:F
Credentials:CPSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:91 E FORT UNION BLVD
Mailing Address - Street 2:
Mailing Address - City:MIDVALE
Mailing Address - State:UT
Mailing Address - Zip Code:84047-1531
Mailing Address - Country:US
Mailing Address - Phone:801-569-1995
Mailing Address - Fax:
Practice Address - Street 1:91 E FORT UNION BLVD
Practice Address - Street 2:
Practice Address - City:MIDVALE
Practice Address - State:UT
Practice Address - Zip Code:84047-1531
Practice Address - Country:US
Practice Address - Phone:801-569-1995
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-25
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT111111111175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist