Provider Demographics
NPI:1093256257
Name:CORONA, MARISA K
Entity Type:Individual
Prefix:MS
First Name:MARISA
Middle Name:K
Last Name:CORONA
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 1:601 BOND AVE NW UNIT 606
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-1493
Mailing Address - Country:US
Mailing Address - Phone:586-295-7040
Mailing Address - Fax:
Practice Address - Street 1:1000 E PARIS AVE SE STE 160
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-8313
Practice Address - Country:US
Practice Address - Phone:586-295-7040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-20
Last Update Date:2021-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1-21-47219103K00000X
247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other