Healthcare Provider Details

I. General information

NPI: 1689396335
Provider Name (Legal Business Name): CARISSA ROSE MARTIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2022
Last Update Date: 08/22/2025
Certification Date: 08/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

407 W GREENLAWN AVE
LANSING MI
48910-2819
US

IV. Provider business mailing address

7815 TRESTLEWOOD DR APT 1A
LANSING MI
48917-8793
US

V. Phone/Fax

Practice location:
  • Phone: 517-882-4000
  • Fax: 517-882-3506
Mailing address:
  • Phone: 810-625-3756
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801119943
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: