Provider Demographics
NPI:1083374524
Name:WOODS, MARISSA
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:WOODS
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 1:2645 LAWNDALE AVE
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-1179
Mailing Address - Country:US
Mailing Address - Phone:847-691-7885
Mailing Address - Fax:
Practice Address - Street 1:2645 LAWNDALE AVE
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-1179
Practice Address - Country:US
Practice Address - Phone:847-691-7885
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-24
Last Update Date:2021-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178003926101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional