Provider Demographics
NPI:1346014982
Name:WILSON, MARISSA
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:WILSON
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 1:1575 DR MARTIN LUTHER KING JR ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-2295
Mailing Address - Country:US
Mailing Address - Phone:317-644-7243
Mailing Address - Fax:
Practice Address - Street 1:1575 DR MARTIN LUTHER KING JR ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-2250
Practice Address - Country:US
Practice Address - Phone:317-264-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-14
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor