Provider Demographics
NPI:1679827471
Name:PERSONIUS, MARISA (LMFT)
Entity Type:Individual
Prefix:MRS
First Name:MARISA
Middle Name:
Last Name:PERSONIUS
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:524 S HOUSTON LAKE RD
Mailing Address - Street 2:SUITE G
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31088-9027
Mailing Address - Country:US
Mailing Address - Phone:478-333-2498
Mailing Address - Fax:478-333-6531
Practice Address - Street 1:524 S HOUSTON LAKE RD
Practice Address - Street 2:SUITE G
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-9027
Practice Address - Country:US
Practice Address - Phone:478-333-2498
Practice Address - Fax:478-333-6531
Is Sole Proprietor?:No
Enumeration Date:2012-10-31
Last Update Date:2012-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1150106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist