Basic Information
| Provider Information | |||||||||
| NPI: | 1356618623 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EDGAR | ||||||||
| FirstName: | CARISSA | ||||||||
| MiddleName: | DAWN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2909 KING ST STE A | ||||||||
| Address2: | |||||||||
| City: | JONESBORO | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724015326 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8708973042 | ||||||||
| FaxNumber: | 8703823025 | ||||||||
| Practice Location | |||||||||
| Address1: | 1815 PLEASANT GROVE ROAD | ||||||||
| Address2: | |||||||||
| City: | JONESBORO | ||||||||
| State: | AR | ||||||||
| PostalCode: | 72401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8709336886 | ||||||||
| FaxNumber: | 8709339395 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2011 | ||||||||
| LastUpdateDate: | 04/13/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 6884-C | AR | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 189554795 | 05 | AR | MEDICAID |