Provider Demographics
NPI:1568720472
Name:SHERMAN, MARISSA ELIZABETH (MS, CMHC, PCI)
Entity Type:Individual
Prefix:MRS
First Name:MARISSA
Middle Name:ELIZABETH
Last Name:SHERMAN
Suffix:
Gender:F
Credentials:MS, CMHC, PCI
Other - Prefix:MRS
Other - First Name:MARISSA
Other - Middle Name:ELIZABETH
Other - Last Name:MACIAS BIRD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4125 N CANYON RD
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-5015
Mailing Address - Country:US
Mailing Address - Phone:408-375-3311
Mailing Address - Fax:866-540-1490
Practice Address - Street 1:9140 S STATE ST
Practice Address - Street 2:SUITE 202
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84070-2684
Practice Address - Country:US
Practice Address - Phone:408-375-3311
Practice Address - Fax:866-540-1490
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-27
Last Update Date:2016-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8173984-6004101YM0800X, 101YP2500X, 101Y00000X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1770721300Medicaid