Provider Demographics
NPI:1871972380
Name:COUNCILL-TRINIDAD, KARISSA KAYLEEN (MA00021954)
Entity type:Individual
Prefix:
First Name:KARISSA
Middle Name:KAYLEEN
Last Name:COUNCILL-TRINIDAD
Suffix:
Gender:F
Credentials:MA00021954
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3223 TULALIP AVE
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-4155
Mailing Address - Country:US
Mailing Address - Phone:425-293-2639
Mailing Address - Fax:
Practice Address - Street 1:3223 TULALIP AVE
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-4155
Practice Address - Country:US
Practice Address - Phone:425-293-2639
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-29
Last Update Date:2015-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00021954174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist