Provider Demographics
NPI:1114563988
Name:CLAYTON, MARISSA NICOAL
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:NICOAL
Last Name:CLAYTON
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 1:1229 SE STATE RTE N
Mailing Address - Street 2:
Mailing Address - City:BUTLER
Mailing Address - State:MO
Mailing Address - Zip Code:64730-8692
Mailing Address - Country:US
Mailing Address - Phone:816-738-0389
Mailing Address - Fax:
Practice Address - Street 1:3002 YOUNGER DR
Practice Address - Street 2:
Practice Address - City:HARRISONVILLE
Practice Address - State:MO
Practice Address - Zip Code:64701-3909
Practice Address - Country:US
Practice Address - Phone:417-448-9766
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-26
Last Update Date:2019-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician