MEDICARE: CARISSA VAN NORMAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1881100816
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARISSA VAN NORMAN

Provider Business Mailing Address
First Line	:	2120 ACADEMY CIR STE H
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80909-1674
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2120 ACADEMY CIR STE H
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80909-1674
Country	:	US
Telephone Number	:	570-460-2202
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/28/2017
Last Update Date	:	12/28/2017

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Directions to “ CARISSA VAN NORMAN ” Practice Location

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