Provider Demographics
NPI:1386005452
Name:SMALL, MARISSA
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:SMALL
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 1:3755 W LAKE MEAD BLVD
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89032-4897
Mailing Address - Country:US
Mailing Address - Phone:702-541-5057
Mailing Address - Fax:
Practice Address - Street 1:3755 W LAKE MEAD BLVD
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89032-4897
Practice Address - Country:US
Practice Address - Phone:702-541-5057
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-16
Last Update Date:2016-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor