Provider Demographics
NPI:1003166596
Name:MOOK, MARISA D (LISW-S)
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:D
Last Name:MOOK
Suffix:
Gender:F
Credentials:LISW-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5204 MAHONING AVE
Mailing Address - Street 2:BUILDING 1, SUITE 105
Mailing Address - City:AUSTINTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44515-1808
Mailing Address - Country:US
Mailing Address - Phone:330-797-0036
Mailing Address - Fax:
Practice Address - Street 1:8440 MARKET ST
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44512
Practice Address - Country:US
Practice Address - Phone:330-965-9999
Practice Address - Fax:330-757-0000
Is Sole Proprietor?:No
Enumeration Date:2012-09-12
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.1500091-S1041C0700X
OHI.15000911041C0700X
1041C0700X, 1041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHPENDINGMedicaid