Provider Demographics
NPI:1679712590
Name:MLYNIEC, KARISSA (MASTERS)
Entity type:Individual
Prefix:
First Name:KARISSA
Middle Name:
Last Name:MLYNIEC
Suffix:
Gender:F
Credentials:MASTERS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:94 JOHN POTTER RD
Mailing Address - Street 2:
Mailing Address - City:WEST GREENWICH
Mailing Address - State:RI
Mailing Address - Zip Code:02817-2099
Mailing Address - Country:US
Mailing Address - Phone:401-937-8473
Mailing Address - Fax:401-365-1100
Practice Address - Street 1:94 JOHN POTTER RD
Practice Address - Street 2:
Practice Address - City:WEST GREENWICH
Practice Address - State:RI
Practice Address - Zip Code:02817-2099
Practice Address - Country:US
Practice Address - Phone:401-937-8473
Practice Address - Fax:401-365-1100
Is Sole Proprietor?:No
Enumeration Date:2009-02-17
Last Update Date:2009-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIGH57134Medicaid