Healthcare Provider Details

I. General information

NPI: 1639684590
Provider Name (Legal Business Name): KARISSA V.L. DELORME-SHIVES MA, LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/13/2017
Last Update Date: 04/20/2022
Certification Date: 04/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2555 S DIXIE DR STE 260
DAYTON OH
45409
US

IV. Provider business mailing address

10100 ELIDA RD
DELPHOS OH
45833-9056
US

V. Phone/Fax

Practice location:
  • Phone: 937-853-9061
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberE.2002043
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: