Provider Demographics
NPI:1699119826
Name:SURACE, CARISSA LYNNE
Entity type:Individual
Prefix:MISS
First Name:CARISSA
Middle Name:LYNNE
Last Name:SURACE
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 1:413 MASSACHUSETTS AVE
Mailing Address - Street 2:APT 1
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-3525
Mailing Address - Country:US
Mailing Address - Phone:541-953-8155
Mailing Address - Fax:
Practice Address - Street 1:50 REDFIELD ST
Practice Address - Street 2:SUITE 300
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02122-3630
Practice Address - Country:US
Practice Address - Phone:617-288-7450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-18
Last Update Date:2013-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist