Provider Demographics
NPI:1598001380
Name:VALDISERRA, MARISA L (MA)
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:L
Last Name:VALDISERRA
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 LAUREL GROVE DR
Mailing Address - Street 2:
Mailing Address - City:HIGGANUM
Mailing Address - State:CT
Mailing Address - Zip Code:06441-4355
Mailing Address - Country:US
Mailing Address - Phone:860-227-1369
Mailing Address - Fax:
Practice Address - Street 1:255 HEMPSTEAD ST
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-6204
Practice Address - Country:US
Practice Address - Phone:860-443-2896
Practice Address - Fax:860-442-5909
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-24
Last Update Date:2019-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2721101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty