Provider Demographics
NPI:1043764160
Name:HEDRICK, MARISSA (LMSW)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:HEDRICK
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 BROADWAY BLVD NE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-2360
Mailing Address - Country:US
Mailing Address - Phone:505-933-4639
Mailing Address - Fax:
Practice Address - Street 1:707 BROADWAY BLVD NE
Practice Address - Street 2:SUITE 103
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-2360
Practice Address - Country:US
Practice Address - Phone:505-933-4639
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-05
Last Update Date:2016-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM-07116104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker