Provider Demographics
NPI:1518504562
Name:RUSSELL, MARISSA LEIGH
Entity Type:Individual
Prefix:MRS
First Name:MARISSA
Middle Name:LEIGH
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:MARISSA
Other - Middle Name:LEIGH
Other - Last Name:MEYERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:422 ALPINE DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-0202
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:422 ALPINE DR
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-0202
Practice Address - Country:US
Practice Address - Phone:401-742-1283
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-09
Last Update Date:2019-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician