Healthcare Provider Details

I. General information

NPI: 1952165508
Provider Name (Legal Business Name): CARISSA NICOLE ROSE RBT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2024
Last Update Date: 05/08/2026
Certification Date: 05/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2125 HEIGHTS DR STE 3H
EAU CLAIRE WI
54701-6146
US

IV. Provider business mailing address

2125 HEIGHTS DR STE 3H
EAU CLAIRE WI
54701-6146
US

V. Phone/Fax

Practice location:
  • Phone: 715-515-0790
  • Fax: 715-318-0170
Mailing address:
  • Phone: 715-515-0790
  • Fax: 715-318-0170

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: