Healthcare Provider Details

I. General information

NPI: 1265026579
Provider Name (Legal Business Name): CARRIE LYNN RISDON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2021
Last Update Date: 01/31/2026
Certification Date: 01/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 FRUITDALE DR
GRANTS PASS OR
97527-5267
US

IV. Provider business mailing address

1215 SW G ST
GRANTS PASS OR
97526-2544
US

V. Phone/Fax

Practice location:
  • Phone: 541-476-2373
  • Fax:
Mailing address:
  • Phone: 541-476-2373
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: