Provider Demographics
NPI:1770215378
Name:MARTIN, MARISA DANIELLE
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:DANIELLE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 SWEET ALYSSUM DR
Mailing Address - Street 2:
Mailing Address - City:LADSON
Mailing Address - State:SC
Mailing Address - Zip Code:29456-3899
Mailing Address - Country:US
Mailing Address - Phone:615-785-7844
Mailing Address - Fax:
Practice Address - Street 1:2070 NORTHBROOK BLVD STE B4
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-9254
Practice Address - Country:US
Practice Address - Phone:843-569-3033
Practice Address - Fax:843-569-6820
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-30
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRBT-19-83211106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician