Provider Demographics
NPI:1134635030
Name:HARRIS, MARISSA PAIGE (LADC)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:PAIGE
Last Name:HARRIS
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:352 STATE STREET
Mailing Address - Street 2:
Mailing Address - City:NORTH HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06473-3108
Mailing Address - Country:US
Mailing Address - Phone:203-781-4624
Mailing Address - Fax:203-781-4624
Practice Address - Street 1:352 STATE STREET
Practice Address - Street 2:
Practice Address - City:NORTH HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06473-2550
Practice Address - Country:US
Practice Address - Phone:203-781-4600
Practice Address - Fax:203-781-4624
Is Sole Proprietor?:No
Enumeration Date:2017-12-14
Last Update Date:2023-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X, 103K00000X
CT1511101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008022626Medicaid
CT008120650Medicaid
CT500000315Medicaid
CT008056168Medicaid
CT004082286Medicaid