Basic Information
| Provider Information | |||||||||
| NPI: | 1356974869 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GLOVER | ||||||||
| FirstName: | CARISSA | ||||||||
| MiddleName: | T | ||||||||
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| Mailing Information | |||||||||
| Address1: | 850 N CENTER AVE APT 36M | ||||||||
| Address2: | |||||||||
| City: | ONTARIO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917644852 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9092923260 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3625 14TH ST | ||||||||
| Address2: | |||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925013815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9519551540 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2020 | ||||||||
| LastUpdateDate: | 02/13/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.