Provider Demographics
NPI:1376049577
Name:DELLAFAVE, MARISSA (MS, LAC)
Entity Type:Individual
Prefix:MS
First Name:MARISSA
Middle Name:
Last Name:DELLAFAVE
Suffix:
Gender:F
Credentials:MS, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:661 SHREWSBURY AVE
Mailing Address - Street 2:
Mailing Address - City:SHREWSBURY
Mailing Address - State:NJ
Mailing Address - Zip Code:07702-4183
Mailing Address - Country:US
Mailing Address - Phone:732-345-3410
Mailing Address - Fax:
Practice Address - Street 1:661 SHREWSBURY AVE
Practice Address - Street 2:
Practice Address - City:SHREWSBURY
Practice Address - State:NJ
Practice Address - Zip Code:07702-4183
Practice Address - Country:US
Practice Address - Phone:732-345-3410
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-05
Last Update Date:2018-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00271000106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist