Provider Demographics
NPI:1467911909
Name:WILSON, MARISSA MARSHE
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:MARSHE
Last Name:WILSON
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 1:2114 NOBLE RD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44112-1725
Mailing Address - Country:US
Mailing Address - Phone:216-268-2400
Mailing Address - Fax:216-268-2460
Practice Address - Street 1:2114 NOBLE RD
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44112-1725
Practice Address - Country:US
Practice Address - Phone:216-268-2400
Practice Address - Fax:216-268-2460
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-14
Last Update Date:2019-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty