Provider Demographics
NPI:1083496194
Name:MAKWINSKI, MARISSA NICOLE
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:NICOLE
Last Name:MAKWINSKI
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 1:751 IVY TRAIL WAY
Mailing Address - Street 2:
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29715-5923
Mailing Address - Country:US
Mailing Address - Phone:803-280-5495
Mailing Address - Fax:
Practice Address - Street 1:751 IVY TRAIL WAY
Practice Address - Street 2:
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29715-5923
Practice Address - Country:US
Practice Address - Phone:803-280-5495
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-16
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst