Provider Demographics
NPI:1528466372
Name:FLEEK, CARISSA
Entity type:Individual
Prefix:
First Name:CARISSA
Middle Name:
Last Name:FLEEK
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 1:6828 CORVALLIS AVE N
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL
Mailing Address - State:MN
Mailing Address - Zip Code:55428-4332
Mailing Address - Country:US
Mailing Address - Phone:763-229-6896
Mailing Address - Fax:
Practice Address - Street 1:10961 CLUB WEST PKWY
Practice Address - Street 2:
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55449-5866
Practice Address - Country:US
Practice Address - Phone:763-506-8440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-10
Last Update Date:2014-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN22892255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer