Provider Demographics
NPI:1992079131
Name:MITCHELL, CARISSA RUTHERFORD (CAC)
Entity type:Individual
Prefix:MRS
First Name:CARISSA
Middle Name:RUTHERFORD
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:CAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901B AIRLINE DR
Mailing Address - Street 2:
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70001-5936
Mailing Address - Country:US
Mailing Address - Phone:504-833-4673
Mailing Address - Fax:504-885-0400
Practice Address - Street 1:1901B AIRLINE DR
Practice Address - Street 2:
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70001-5936
Practice Address - Country:US
Practice Address - Phone:504-833-4673
Practice Address - Fax:504-885-0400
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-06
Last Update Date:2012-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1404101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)