Provider Demographics
NPI:1407632284
Name:NICHOLS, MARISSA CASTINE
Entity Type:Individual
Prefix:MS
First Name:MARISSA
Middle Name:CASTINE
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:MARISSA
Other - Middle Name:CASTINE
Other - Last Name:WALTERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:826 1ST AVE N
Mailing Address - Street 2:
Mailing Address - City:FORT DODGE
Mailing Address - State:IA
Mailing Address - Zip Code:50501-3997
Mailing Address - Country:US
Mailing Address - Phone:515-573-3931
Mailing Address - Fax:
Practice Address - Street 1:826 1ST AVE N
Practice Address - Street 2:
Practice Address - City:FORT DODGE
Practice Address - State:IA
Practice Address - Zip Code:50501-3997
Practice Address - Country:US
Practice Address - Phone:515-573-3931
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-06
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)