Healthcare Provider Details

I. General information

NPI: 1356974869
Provider Name (Legal Business Name): CARISSA T GLOVER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2020
Last Update Date: 02/13/2020
Certification Date: 02/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3625 14TH ST
RIVERSIDE CA
92501-3815
US

IV. Provider business mailing address

850 N CENTER AVE APT 36M
ONTARIO CA
91764-4852
US

V. Phone/Fax

Practice location:
  • Phone: 951-955-1540
  • Fax:
Mailing address:
  • Phone: 909-292-3260
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: