Provider Demographics
NPI:1174136683
Name:MOONEY, KARISSA LYNN (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:KARISSA
Middle Name:LYNN
Last Name:MOONEY
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 VANDERBILT AVE APT 215
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11238-3486
Mailing Address - Country:US
Mailing Address - Phone:631-678-2582
Mailing Address - Fax:
Practice Address - Street 1:55 WILLOUGHBY ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-5211
Practice Address - Country:US
Practice Address - Phone:718-305-4199
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-25
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY029462235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist