1528429396 NPI number — KARISSA DANIELLE DESIDERIO MSW

Table of content: KARISSA DANIELLE DESIDERIO MSW (NPI 1528429396)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528429396 NPI number — KARISSA DANIELLE DESIDERIO MSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DESIDERIO
Provider First Name:
KARISSA
Provider Middle Name:
DANIELLE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1528429396
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1202 FAUN RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WILMINGTON
Provider Business Mailing Address State Name:
DE
Provider Business Mailing Address Postal Code:
19803-3317
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-937-2511
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
327 W. BALTIMORE PIKE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLIFTON HEIGHTS
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19017
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-937-2511
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/08/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 251B00000X , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 103075320 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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