Provider Demographics
NPI:1336972819
Name:HENNESSEY, CORISSA ANNE (LMSW)
Entity type:Individual
Prefix:
First Name:CORISSA
Middle Name:ANNE
Last Name:HENNESSEY
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:CORISSA
Other - Middle Name:
Other - Last Name:CRADDICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10300 LONE TREE DR
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99507-6920
Mailing Address - Country:US
Mailing Address - Phone:512-771-5604
Mailing Address - Fax:
Practice Address - Street 1:3001 C ST
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99503-3913
Practice Address - Country:US
Practice Address - Phone:907-201-5670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-21
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK209097104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker