Provider Demographics
NPI:1194360131
Name:COX, MARRISA ANN
Entity Type:Individual
Prefix:
First Name:MARRISA
Middle Name:ANN
Last Name:COX
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 1:10452 LODGE DR APT E14
Mailing Address - Street 2:
Mailing Address - City:ALLENDALE
Mailing Address - State:MI
Mailing Address - Zip Code:49401-7383
Mailing Address - Country:US
Mailing Address - Phone:810-938-2506
Mailing Address - Fax:
Practice Address - Street 1:348 S WAVERLY RD # 25
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-3799
Practice Address - Country:US
Practice Address - Phone:616-377-2135
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-13
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI200585067102106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician