Provider Demographics
NPI:1740874163
Name:NICHOLS, MARISSA (MSW, LLMSW)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:MSW, LLMSW
Other - Prefix:
Other - First Name:RIZZO
Other - Middle Name:
Other - Last Name:NICHOLS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MSW, LLMSW
Mailing Address - Street 1:31521 NELSON DR
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48088-1865
Mailing Address - Country:US
Mailing Address - Phone:586-899-2898
Mailing Address - Fax:
Practice Address - Street 1:15350 N COMMERCE DR STE 204
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48120-1234
Practice Address - Country:US
Practice Address - Phone:313-203-2077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-25
Last Update Date:2021-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011087931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical