Provider Demographics
NPI:1720600323
Name:TOLLEY, MARISSA BETH (LGSW)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:BETH
Last Name:TOLLEY
Suffix:
Gender:F
Credentials:LGSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 PROFESSIONAL PL STE 102
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-0259
Mailing Address - Country:US
Mailing Address - Phone:304-848-5770
Mailing Address - Fax:
Practice Address - Street 1:65 PROFESSIONAL PL STE 102
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-0259
Practice Address - Country:US
Practice Address - Phone:304-848-5770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-18
Last Update Date:2020-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVSW032015451104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker