Provider Demographics
NPI:1093468910
Name:SORCE, MARISSA MARIE
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:MARIE
Last Name:SORCE
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 1:930 BLACKJACK RIDGE TRL
Mailing Address - Street 2:
Mailing Address - City:LAKE HELEN
Mailing Address - State:FL
Mailing Address - Zip Code:32744-3386
Mailing Address - Country:US
Mailing Address - Phone:386-785-5188
Mailing Address - Fax:
Practice Address - Street 1:140 S BEACH ST STE 310
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-4409
Practice Address - Country:US
Practice Address - Phone:386-785-5188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-31
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist