Basic Information
| Provider Information | |||||||||
| NPI: | 1174860324 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BROWN | ||||||||
| FirstName: | CARISSA | ||||||||
| MiddleName: | RENEE | ||||||||
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| Credential: | MA, LCMHCS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 284 EXECUTIVE PARK DR STE 100 | ||||||||
| Address2: | |||||||||
| City: | CONCORD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280251833 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7049391100 | ||||||||
| FaxNumber: | 7049391173 | ||||||||
| Practice Location | |||||||||
| Address1: | 1105 E CARDINAL ST | ||||||||
| Address2: | |||||||||
| City: | SILER CITY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 273443300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9196632955 | ||||||||
| FaxNumber: | 9197997713 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/08/2013 | ||||||||
| LastUpdateDate: | 06/28/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 9147 | NC | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 1174860324 | 01 | NC | HUMANA | OTHER | 19H2H | 01 | NC | BCBS | OTHER | 601121-450 | 01 | NC | MAGELLAN | OTHER | 1174860324 | 05 | NC | MEDICAID |