Provider Demographics
NPI:1497230684
Name:KOUROYEN, MARISA GLYNN
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:GLYNN
Last Name:KOUROYEN
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 1:35 EDGAR AVE
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02145-1450
Mailing Address - Country:US
Mailing Address - Phone:860-389-7535
Mailing Address - Fax:
Practice Address - Street 1:853 TURNPIKE ST STE 241
Practice Address - Street 2:
Practice Address - City:NORTH ANDOVER
Practice Address - State:MA
Practice Address - Zip Code:01845-6172
Practice Address - Country:US
Practice Address - Phone:860-389-7535
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-03
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA13021-MH-CC101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health