Provider Demographics
NPI:1093234841
Name:SPEARS, MARISA
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:
Last Name:SPEARS
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 1:1 MOOCK RD STE 101
Mailing Address - Street 2:
Mailing Address - City:WILDER
Mailing Address - State:KY
Mailing Address - Zip Code:41071-5465
Mailing Address - Country:US
Mailing Address - Phone:859-341-9333
Mailing Address - Fax:859-341-9444
Practice Address - Street 1:1 MOOCK RD STE 101
Practice Address - Street 2:
Practice Address - City:WILDER
Practice Address - State:KY
Practice Address - Zip Code:41071-5465
Practice Address - Country:US
Practice Address - Phone:859-630-7081
Practice Address - Fax:859-341-9444
Is Sole Proprietor?:No
Enumeration Date:2017-09-13
Last Update Date:2017-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical