Provider Demographics
NPI:1730705955
Name:REYES, CARISSA (CSW)
Entity type:Individual
Prefix:
First Name:CARISSA
Middle Name:
Last Name:REYES
Suffix:
Gender:F
Credentials:CSW
Other - Prefix:
Other - First Name:CARISSA
Other - Middle Name:REYES
Other - Last Name:DELAHUNTY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CSW
Mailing Address - Street 1:11618 S STATE ST STE 1604
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-7123
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11618 S STATE ST STE 1604
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-7123
Practice Address - Country:US
Practice Address - Phone:385-202-5645
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-23
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11782053-35021041C0700X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical