Provider Demographics
NPI:1073242285
Name:DWYER, MARISSA JOANNE
Entity Type:Individual
Prefix:MISS
First Name:MARISSA
Middle Name:JOANNE
Last Name:DWYER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:435 WINDY HILL RD
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CT
Mailing Address - Zip Code:06477-2142
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2666 STATE STREET
Practice Address - Street 2:UNTI A3
Practice Address - City:HAMDEN
Practice Address - State:CT
Practice Address - Zip Code:06517
Practice Address - Country:US
Practice Address - Phone:888-754-0398
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-06
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTXGY014W03536OtherANTHEM BLUE CROSS BLUE SHIELD