Healthcare Provider Details

I. General information

NPI: 1548530561
Provider Name (Legal Business Name): CARISSA WOTT PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CARISSA COIT

II. Dates (important events)

Enumeration Date: 01/06/2012
Last Update Date: 08/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 W SOUTH BOUNDARY ST
PERRYSBURG OH
43551
US

IV. Provider business mailing address

830 W SOUTH BOUNDARY ST
PERRYSBURG OH
43551-5238
US

V. Phone/Fax

Practice location:
  • Phone: 419-931-3020
  • Fax: 419-931-3022
Mailing address:
  • Phone: 419-931-3020
  • Fax: 419-931-3022

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6875
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number6875
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: