Provider Demographics
NPI:1417600982
Name:DOUGLAS, MARISSA LEE (LMHC)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:LEE
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1042 CLARKSON PARMA TL RD
Mailing Address - Street 2:
Mailing Address - City:HILTON
Mailing Address - State:NY
Mailing Address - Zip Code:14468-9709
Mailing Address - Country:US
Mailing Address - Phone:585-749-3274
Mailing Address - Fax:
Practice Address - Street 1:300 WEST AVE
Practice Address - Street 2:
Practice Address - City:BROCKPORT
Practice Address - State:NY
Practice Address - Zip Code:14420-1118
Practice Address - Country:US
Practice Address - Phone:585-637-3905
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-03
Last Update Date:2022-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011838-01101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health