Provider Demographics
NPI:1588003560
Name:ALLEN, MARISSA
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:ALLEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417 FOREST ST STE 467
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49001-2747
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16587 ENTERPRISE DR
Practice Address - Street 2:
Practice Address - City:THREE RIVERS
Practice Address - State:MI
Practice Address - Zip Code:49093-7902
Practice Address - Country:US
Practice Address - Phone:734-429-7938
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-23
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA11212330103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst