Provider Demographics
NPI:1356974869
Name:GLOVER, CARISSA T
Entity type:Individual
Prefix:
First Name:CARISSA
Middle Name:T
Last Name:GLOVER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 N CENTER AVE APT 36M
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91764-4852
Mailing Address - Country:US
Mailing Address - Phone:909-292-3260
Mailing Address - Fax:
Practice Address - Street 1:3625 14TH ST
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501-3815
Practice Address - Country:US
Practice Address - Phone:951-955-1540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-13
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health