Basic Information
Provider Information | |||||||||
NPI: | 1033598396 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GODEL | ||||||||
FirstName: | KARISSA | ||||||||
MiddleName: | JOY | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MS, LPCC, LADC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 7945 STONE CREEK DR | ||||||||
Address2: | SUITE 140 | ||||||||
City: | CHANHASSEN | ||||||||
State: | MN | ||||||||
PostalCode: | 553174605 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9529743999 | ||||||||
FaxNumber: | 9529743780 | ||||||||
Practice Location | |||||||||
Address1: | 7945 STONE CREEK DR | ||||||||
Address2: | SUITE 140 | ||||||||
City: | CHANHASSEN | ||||||||
State: | MN | ||||||||
PostalCode: | 553174605 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9529743999 | ||||||||
FaxNumber: | 9529743780 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/20/2015 | ||||||||
LastUpdateDate: | 05/20/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 304064 | MN | N |   | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | 951 | MN | Y |   | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.