Provider Demographics
NPI:1417096587
Name:PETERSON, MARISSA LEIGH (MS, LPC)
Entity Type:Individual
Prefix:MS
First Name:MARISSA
Middle Name:LEIGH
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MS, LPC
Other - Prefix:
Other - First Name:MARISSA
Other - Middle Name:
Other - Last Name:CIRINCIONE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1800 COMMUNITY
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MO
Mailing Address - Zip Code:64735-8804
Mailing Address - Country:US
Mailing Address - Phone:660-885-8131
Mailing Address - Fax:
Practice Address - Street 1:1905 STADIUM BLVD
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109
Practice Address - Country:US
Practice Address - Phone:888-403-1071
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2018-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007017523101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional