Healthcare Provider Details

I. General information

NPI: 1679292957
Provider Name (Legal Business Name): KARISSA CONSUELO HARRILL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2022
Last Update Date: 08/22/2022
Certification Date: 08/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41701 STETSON AVE
HEMET CA
92544-7598
US

IV. Provider business mailing address

32216 CORTE CHATADA
TEMECULA CA
92592-6320
US

V. Phone/Fax

Practice location:
  • Phone: 951-765-5150
  • Fax:
Mailing address:
  • Phone: 619-890-8468
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number30767
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: