Provider Demographics
NPI:1174024988
Name:ROTHROCK, MARISA MANCINI
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:MANCINI
Last Name:ROTHROCK
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 1:1814 DON FELIPE RD SW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87105-6654
Mailing Address - Country:US
Mailing Address - Phone:505-321-0906
Mailing Address - Fax:
Practice Address - Street 1:7850 JEFFERSON ST NE STE 300
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-4314
Practice Address - Country:US
Practice Address - Phone:505-884-1114
Practice Address - Fax:505-884-3004
Is Sole Proprietor?:No
Enumeration Date:2018-02-27
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCCMH0222441101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional