Provider Demographics
NPI:1679920854
Name:CARTY, KARISSA (ATC)
Entity type:Individual
Prefix:
First Name:KARISSA
Middle Name:
Last Name:CARTY
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 ESSEX AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07003-2866
Mailing Address - Country:US
Mailing Address - Phone:973-207-7508
Mailing Address - Fax:
Practice Address - Street 1:285 MADISON AVE
Practice Address - Street 2:M-RC2-01
Practice Address - City:MADISON
Practice Address - State:NJ
Practice Address - Zip Code:07940-1006
Practice Address - Country:US
Practice Address - Phone:973-443-8874
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-18
Last Update Date:2016-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MT002012002255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer