Provider Demographics
NPI:1063017515
Name:HERNANDEZ, MARISSA (LPC-A)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:LPC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6090 SURETY DR STE 107
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79905-2060
Mailing Address - Country:US
Mailing Address - Phone:915-301-0174
Mailing Address - Fax:
Practice Address - Street 1:6090 SURETY DR STE 107
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79905-2060
Practice Address - Country:US
Practice Address - Phone:915-301-0174
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-02
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health