Provider Demographics
NPI:1053152421
Name:FRAZIER, KERISSA J
Entity type:Individual
Prefix:
First Name:KERISSA
Middle Name:J
Last Name:FRAZIER
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 1:98 MAYFIELD DR
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:TN
Mailing Address - Zip Code:37167-3033
Mailing Address - Country:US
Mailing Address - Phone:816-287-2088
Mailing Address - Fax:
Practice Address - Street 1:98 MAYFIELD DR
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:TN
Practice Address - Zip Code:37167-3033
Practice Address - Country:US
Practice Address - Phone:816-287-2088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-01
Last Update Date:2024-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN000569172101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchoolGroup - Multi-Specialty