Provider Demographics
NPI:1497234132
Name:MOSS, MARISA LEIGH
Entity Type:Individual
Prefix:MRS
First Name:MARISA
Middle Name:LEIGH
Last Name:MOSS
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:MARISA
Other - Middle Name:LEIGH
Other - Last Name:SINGSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4423 N COUNTRY WOOD DR
Mailing Address - Street 2:
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043-4769
Mailing Address - Country:US
Mailing Address - Phone:385-528-5962
Mailing Address - Fax:
Practice Address - Street 1:750 N FREEDOM BLVD
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84601
Practice Address - Country:US
Practice Address - Phone:801-373-4760
Practice Address - Fax:801-373-0639
Is Sole Proprietor?:No
Enumeration Date:2018-08-13
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
UT11295956-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor