Provider Demographics
NPI:1568757557
Name:MARQUEZ, ALLISSA (PHD)
Entity Type:Individual
Prefix:
First Name:ALLISSA
Middle Name:
Last Name:MARQUEZ
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4220 HOLDEN RD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27616-8917
Mailing Address - Country:US
Mailing Address - Phone:919-737-2166
Mailing Address - Fax:
Practice Address - Street 1:2809 SPRING FOREST RD STE 103
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27616-1898
Practice Address - Country:US
Practice Address - Phone:919-737-2166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-17
Last Update Date:2023-04-12
Deactivation Date:2023-02-28
Deactivation Code:
Reactivation Date:2023-04-06
Provider Licenses
StateLicense IDTaxonomies
390200000X
NC4955103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program