Provider Demographics
NPI:1043857527
Name:WALLACE, MARISSA STEEN (LSW)
Entity Type:Individual
Prefix:MS
First Name:MARISSA
Middle Name:STEEN
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1750 30TH ST # 435
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-1029
Mailing Address - Country:US
Mailing Address - Phone:817-734-6961
Mailing Address - Fax:
Practice Address - Street 1:4251 KIPLING ST UNIT 560
Practice Address - Street 2:
Practice Address - City:WHEAT RIDGE
Practice Address - State:CO
Practice Address - Zip Code:80033-6800
Practice Address - Country:US
Practice Address - Phone:720-490-7911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-04
Last Update Date:2019-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLSW.0009921712104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker