Provider Demographics
NPI:1629116975
Name:MARSH, MARISSA JANE
Entity Type:Individual
Prefix:MRS
First Name:MARISSA
Middle Name:JANE
Last Name:MARSH
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:MARISSA
Other - Middle Name:JANE
Other - Last Name:JOHNSTON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1398 MARIGOLD PL
Mailing Address - Street 2:
Mailing Address - City:ROHNERT PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94928-8123
Mailing Address - Country:US
Mailing Address - Phone:707-571-5536
Mailing Address - Fax:
Practice Address - Street 1:411 RUSSELL AVE
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-2219
Practice Address - Country:US
Practice Address - Phone:707-362-0087
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1779Medicare ID - Type Unspecified