Provider Demographics
NPI:1033569868
Name:O'NEILL, MARISSA LYNN (TLLP)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:LYNN
Last Name:O'NEILL
Suffix:
Gender:F
Credentials:TLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4187 BROCKWAY RD
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48638-4776
Mailing Address - Country:US
Mailing Address - Phone:616-894-6744
Mailing Address - Fax:
Practice Address - Street 1:218 FAST ICE DR
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48642-6167
Practice Address - Country:US
Practice Address - Phone:989-631-2320
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-13
Last Update Date:2016-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301016706103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist