Provider Demographics
NPI:1134637937
Name:MOORE, MARISSA OPAL (LPC)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:OPAL
Last Name:MOORE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27561 E LOGAN RD
Mailing Address - Street 2:
Mailing Address - City:WALKER
Mailing Address - State:MO
Mailing Address - Zip Code:64790-8612
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:815 S ASH ST
Practice Address - Street 2:
Practice Address - City:NEVADA
Practice Address - State:MO
Practice Address - Zip Code:64772-3222
Practice Address - Country:US
Practice Address - Phone:417-667-8352
Practice Address - Fax:417-667-9216
Is Sole Proprietor?:No
Enumeration Date:2018-01-15
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017044142101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional