Provider Demographics
NPI:1528401759
Name:PETERSEN-COLEMAN, MARISSA NICOLE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MARISSA
Middle Name:NICOLE
Last Name:PETERSEN-COLEMAN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6020 DAWSON BLVD
Mailing Address - Street 2:I
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30093-1229
Mailing Address - Country:US
Mailing Address - Phone:770-662-0249
Mailing Address - Fax:
Practice Address - Street 1:111 COLCHESTER AVE
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401
Practice Address - Country:US
Practice Address - Phone:802-847-3634
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-08
Last Update Date:2018-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY003680103TC0700X
VT048.0132241103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical