Provider Demographics
NPI:1255529798
Name:BOKELBERG, CARISSA LYN (PSYD)
Entity type:Individual
Prefix:DR
First Name:CARISSA
Middle Name:LYN
Last Name:BOKELBERG
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4640 S CARROLLTON AVE
Mailing Address - Street 2:SUITE 235
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70119-6051
Mailing Address - Country:US
Mailing Address - Phone:504-780-1702
Mailing Address - Fax:504-780-1705
Practice Address - Street 1:4640 S CARROLLTON AVE
Practice Address - Street 2:SUITE 235
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70119-6051
Practice Address - Country:US
Practice Address - Phone:504-780-1702
Practice Address - Fax:504-780-1705
Is Sole Proprietor?:No
Enumeration Date:2007-10-10
Last Update Date:2011-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1048103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1307424Medicaid