Provider Demographics
NPI:1386134484
Name:WITHAM, CARISSA MICHELLE (LCSW)
Entity type:Individual
Prefix:
First Name:CARISSA
Middle Name:MICHELLE
Last Name:WITHAM
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1041 E YORBA LINDA BLVD STE 202
Mailing Address - Street 2:
Mailing Address - City:PLACENTIA
Mailing Address - State:CA
Mailing Address - Zip Code:92870-3760
Mailing Address - Country:US
Mailing Address - Phone:800-701-0937
Mailing Address - Fax:
Practice Address - Street 1:1041 E YORBA LINDA BLVD
Practice Address - Street 2:
Practice Address - City:PLACENTIA
Practice Address - State:CA
Practice Address - Zip Code:92870-3728
Practice Address - Country:US
Practice Address - Phone:800-701-0937
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-14
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA928421041C0700X
171M00000X
CA1151991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7420Medicaid
CA6758Medicaid
CA7068Medicaid