Provider Demographics
NPI:1922541853
Name:PINK, MARISA
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:
Last Name:PINK
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 1:1 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FLEETWOOD
Mailing Address - State:PA
Mailing Address - Zip Code:19522-1323
Mailing Address - Country:US
Mailing Address - Phone:610-944-0445
Mailing Address - Fax:610-944-8834
Practice Address - Street 1:90 S COMMERCE WAY STE 300
Practice Address - Street 2:
Practice Address - City:BETHLEHEM
Practice Address - State:PA
Practice Address - Zip Code:18017-8611
Practice Address - Country:US
Practice Address - Phone:610-691-8401
Practice Address - Fax:610-691-0647
Is Sole Proprietor?:No
Enumeration Date:2016-11-26
Last Update Date:2016-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW132099104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker