Provider Demographics
NPI:1861740516
Name:LEE, CARISSA (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:CARISSA
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:558 E 2ND ST
Mailing Address - Street 2:P.O. BOX 1191
Mailing Address - City:POWELL
Mailing Address - State:WY
Mailing Address - Zip Code:82435-2001
Mailing Address - Country:US
Mailing Address - Phone:307-754-2864
Mailing Address - Fax:
Practice Address - Street 1:558 E 2ND ST
Practice Address - Street 2:
Practice Address - City:POWELL
Practice Address - State:WY
Practice Address - Zip Code:82435-2001
Practice Address - Country:US
Practice Address - Phone:307-754-2864
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-28
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist