Provider Demographics
NPI:1932749199
Name:KNOTT, CARISSA MAE
Entity type:Individual
Prefix:
First Name:CARISSA
Middle Name:MAE
Last Name:KNOTT
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 1:188 CALDER AVE SE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:MN
Mailing Address - Zip Code:55313-4817
Mailing Address - Country:US
Mailing Address - Phone:763-807-2957
Mailing Address - Fax:
Practice Address - Street 1:303 CATLIN ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:MN
Practice Address - Zip Code:55313-1947
Practice Address - Country:US
Practice Address - Phone:763-682-1212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-15
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNTL5756225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist