Provider Demographics
NPI:1790717395
Name:SCHONGALLA, MARISA ANN (PSYD)
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:ANN
Last Name:SCHONGALLA
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5958 N CANTON CENTER RD STE 900
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-2740
Mailing Address - Country:US
Mailing Address - Phone:734-751-7042
Mailing Address - Fax:734-737-1205
Practice Address - Street 1:5958 N CANTON CENTER RD
Practice Address - Street 2:#900
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48187-2765
Practice Address - Country:US
Practice Address - Phone:734-737-1200
Practice Address - Fax:734-737-1205
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2016-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301012822103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical