Provider Demographics
NPI:1114612710
Name:LONDON, MARISSA STEPHANIE (LAC)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:STEPHANIE
Last Name:LONDON
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:470 RIDGEDALE AVE STE 32A
Mailing Address - Street 2:
Mailing Address - City:EAST HANOVER
Mailing Address - State:NJ
Mailing Address - Zip Code:07936-3074
Mailing Address - Country:US
Mailing Address - Phone:973-515-1216
Mailing Address - Fax:973-515-3108
Practice Address - Street 1:470 RIDGEDALE AVE STE 32A
Practice Address - Street 2:
Practice Address - City:EAST HANOVER
Practice Address - State:NJ
Practice Address - Zip Code:07936-3074
Practice Address - Country:US
Practice Address - Phone:973-515-1216
Practice Address - Fax:973-515-3108
Is Sole Proprietor?:No
Enumeration Date:2023-04-10
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00711100101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor