Provider Demographics
NPI:1306193958
Name:WEICK, MARISSA (LSW)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:WEICK
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2475 MCCLELLAN AVE
Mailing Address - Street 2:
Mailing Address - City:PENNSAUKEN
Mailing Address - State:NJ
Mailing Address - Zip Code:08109-4683
Mailing Address - Country:US
Mailing Address - Phone:856-675-3661
Mailing Address - Fax:
Practice Address - Street 1:2475 MCCLELLAN AVENUE
Practice Address - Street 2:
Practice Address - City:PENNSAUKEN
Practice Address - State:NJ
Practice Address - Zip Code:08109
Practice Address - Country:US
Practice Address - Phone:856-675-3661
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-13
Last Update Date:2012-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL057078001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical