Provider Demographics
NPI:1154674257
Name:CHURCH, MARISSA
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:CHURCH
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 1:406 SUNRISE AVE
Mailing Address - Street 2:STE 310
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-4125
Mailing Address - Country:US
Mailing Address - Phone:916-782-3737
Mailing Address - Fax:
Practice Address - Street 1:406 SUNRISE AVE
Practice Address - Street 2:STE 310
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-4125
Practice Address - Country:US
Practice Address - Phone:916-782-3737
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-26
Last Update Date:2012-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)