Provider Demographics
NPI:1497339493
Name:ILAC, MARISSA MAE (LCPC)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:MAE
Last Name:ILAC
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:MARISSA
Other - Middle Name:MAE
Other - Last Name:ILAC
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCPC
Mailing Address - Street 1:PO BOX 731
Mailing Address - Street 2:
Mailing Address - City:HOT SPRINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59845-0731
Mailing Address - Country:US
Mailing Address - Phone:406-260-1716
Mailing Address - Fax:
Practice Address - Street 1:402 1ST ST. E. #205
Practice Address - Street 2:
Practice Address - City:POLSON
Practice Address - State:MT
Practice Address - Zip Code:59860
Practice Address - Country:US
Practice Address - Phone:406-260-1716
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-06
Last Update Date:2021-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-LCPC-LIC-48659101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health