Provider Demographics
NPI:1528429396
Name:DESIDERIO, KARISSA DANIELLE (MSW)
Entity type:Individual
Prefix:
First Name:KARISSA
Middle Name:DANIELLE
Last Name:DESIDERIO
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1202 FAUN RD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19803-3317
Mailing Address - Country:US
Mailing Address - Phone:410-937-2511
Mailing Address - Fax:
Practice Address - Street 1:327 W. BALTIMORE PIKE
Practice Address - Street 2:
Practice Address - City:CLIFTON HEIGHTS
Practice Address - State:PA
Practice Address - Zip Code:19017
Practice Address - Country:US
Practice Address - Phone:410-937-2511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-08
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA251B00000X
251X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
No251X00000XAgenciesSupports Brokerage
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103075320Medicaid