Provider Demographics
NPI:1174879662
Name:SWILLEY, CARISSA MARIE
Entity type:Individual
Prefix:MRS
First Name:CARISSA
Middle Name:MARIE
Last Name:SWILLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 HATHERLEIGH RD
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13209-2232
Mailing Address - Country:US
Mailing Address - Phone:315-430-7223
Mailing Address - Fax:
Practice Address - Street 1:5820 HERITAGE LANDING DR
Practice Address - Street 2:
Practice Address - City:EAST SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13057-9378
Practice Address - Country:US
Practice Address - Phone:315-701-1107
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-02
Last Update Date:2012-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency