Provider Demographics
NPI:1689138430
Name:SIEGEL, MARISSA ELLEN (QMHS)
Entity Type:Individual
Prefix:MRS
First Name:MARISSA
Middle Name:ELLEN
Last Name:SIEGEL
Suffix:
Gender:F
Credentials:QMHS
Other - Prefix:MS
Other - First Name:MARISSA
Other - Middle Name:ELLEN
Other - Last Name:SANDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:375 APPLE TREE DR.
Mailing Address - Street 2:
Mailing Address - City:IONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48846-7506
Mailing Address - Country:US
Mailing Address - Phone:616-527-1790
Mailing Address - Fax:616-527-0538
Practice Address - Street 1:375 APPLE TREE DR.
Practice Address - Street 2:
Practice Address - City:IONIA
Practice Address - State:MI
Practice Address - Zip Code:48846-7506
Practice Address - Country:US
Practice Address - Phone:616-527-1790
Practice Address - Fax:616-527-0538
Is Sole Proprietor?:No
Enumeration Date:2019-01-25
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI101Y00000X
101Y00000X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1715928Medicaid