Healthcare Provider Details

I. General information

NPI: 1851873046
Provider Name (Legal Business Name): CARISSA MALEVICH PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CARISSA ERICKSON

II. Dates (important events)

Enumeration Date: 09/04/2018
Last Update Date: 07/01/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4700 S WASHINGTON ST STE G
GRAND FORKS ND
58201-8155
US

IV. Provider business mailing address

4700 S WASHINGTON ST STE G
GRAND FORKS ND
58201-8155
US

V. Phone/Fax

Practice location:
  • Phone: 701-746-6336
  • Fax: 701-772-1030
Mailing address:
  • Phone: 701-746-6336
  • Fax: 701-772-1030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number569
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: