Provider Demographics
NPI:1487176533
Name:VAN, CARISSA
Entity type:Individual
Prefix:
First Name:CARISSA
Middle Name:
Last Name:VAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 PEACH ST
Mailing Address - Street 2:
Mailing Address - City:BRAINTREE
Mailing Address - State:MA
Mailing Address - Zip Code:02184-8112
Mailing Address - Country:US
Mailing Address - Phone:781-664-3500
Mailing Address - Fax:
Practice Address - Street 1:460 QUINCY AVE
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169-8130
Practice Address - Country:US
Practice Address - Phone:800-852-2844
Practice Address - Fax:617-786-9894
Is Sole Proprietor?:No
Enumeration Date:2017-07-11
Last Update Date:2017-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health