Provider Demographics
NPI:1366861551
Name:MAPLE, MARISSA L (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:MARISSA
Middle Name:L
Last Name:MAPLE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MRS
Other - First Name:MARISSA
Other - Middle Name:L
Other - Last Name:MAPLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1187 QUEEN ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06489-1266
Mailing Address - Country:US
Mailing Address - Phone:860-255-4502
Mailing Address - Fax:
Practice Address - Street 1:1187 QUEEN ST
Practice Address - Street 2:
Practice Address - City:SOUTHINGTON
Practice Address - State:CT
Practice Address - Zip Code:06489-1266
Practice Address - Country:US
Practice Address - Phone:860-255-4502
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-15
Last Update Date:2023-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTPTN.0011947183700000X
CT92671041C0700X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No183700000XPharmacy Service ProvidersPharmacy Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT060669107OtherUNITED BEHAVIORAL HEALTH WELLMORE GRP/FACILITY
CTPENDINGOtherAETNA BEHAVIORAL HEALTH
CT008060347Medicaid
CT060669107OtherUBH OXFORD/FREEDOM/LIBERTY WELLMORE GRP/FACILITY
CTPENDINGOtherMHN TRICARE NORTH
CTPENDINGOtherCIGNA BEHAVIORAL HEALTH
CT060669107OtherANTHEM BCBS OF CT WELLMORE GRP/FACILITY
CT060669107OtherUBH-UNITED HEALTHCARE WELLMORE GRP/FACILITY
CT060669107OtherUBH-CONNECTICARE WELLMORE GRP/FACILITY
CTD339209OtherVALUE OPTIONS/BEACON HEALTH STRATEGIES
CT13559521OtherCAQH
CTPENDINGOtherMHN MANAGED HEALTH NETWORK
CT008060347Medicaid
CT13559521OtherCAQH