Provider Demographics
NPI:1346547940
Name:WACHLAROWICZ, MARISSA MARIE (PHD, T-LP)
Entity Type:Individual
Prefix:DR
First Name:MARISSA
Middle Name:MARIE
Last Name:WACHLAROWICZ
Suffix:
Gender:F
Credentials:PHD, T-LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:673 MDG
Mailing Address - Street 2:5955 ZEAMER AVENUE
Mailing Address - City:JBER
Mailing Address - State:AK
Mailing Address - Zip Code:99506-3700
Mailing Address - Country:US
Mailing Address - Phone:907-580-2181
Mailing Address - Fax:
Practice Address - Street 1:673 MDG
Practice Address - Street 2:5955 ZEAMER AVENUE
Practice Address - City:JBER
Practice Address - State:AK
Practice Address - Zip Code:99506-3700
Practice Address - Country:US
Practice Address - Phone:907-580-2181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-16
Last Update Date:2018-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1352103T00000X
KS2068103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist