Provider Demographics
NPI:1689396335
Name:MARTIN, CARISSA ROSE
Entity type:Individual
Prefix:
First Name:CARISSA
Middle Name:ROSE
Last Name:MARTIN
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 1:7815 TRESTLEWOOD DR APT 1A
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48917-8793
Mailing Address - Country:US
Mailing Address - Phone:810-625-3756
Mailing Address - Fax:
Practice Address - Street 1:1710 E MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48912-2825
Practice Address - Country:US
Practice Address - Phone:517-372-9163
Practice Address - Fax:517-372-7981
Is Sole Proprietor?:No
Enumeration Date:2022-09-19
Last Update Date:2025-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68511150101041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical