Provider Demographics
NPI:1114502044
Name:WITTS, MARISSA
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:WITTS
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 1:9537 DAWN RD NE
Mailing Address - Street 2:
Mailing Address - City:SHERRODSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44675-9024
Mailing Address - Country:US
Mailing Address - Phone:330-401-6531
Mailing Address - Fax:
Practice Address - Street 1:2650 LODGE RD SW
Practice Address - Street 2:
Practice Address - City:SHERRODSVILLE
Practice Address - State:OH
Practice Address - Zip Code:44675-9718
Practice Address - Country:US
Practice Address - Phone:740-200-3800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-11
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH406288163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
3304016531OtherN./A