Provider Demographics
NPI:1487375853
Name:VIGIL, KARYSSA
Entity type:Individual
Prefix:
First Name:KARYSSA
Middle Name:
Last Name:VIGIL
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 1:2090 CORONA DEL SIRE DR
Mailing Address - Street 2:
Mailing Address - City:NORTH FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33917-6755
Mailing Address - Country:US
Mailing Address - Phone:605-872-8955
Mailing Address - Fax:
Practice Address - Street 1:1490 NE PINE ISLAND RD STE 7E-F
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33909-2135
Practice Address - Country:US
Practice Address - Phone:239-599-8733
Practice Address - Fax:239-599-8602
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-06
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-22-233041106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty