Provider Demographics
NPI:1922745397
Name:GILMORE, MARISSA LEIGH
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:LEIGH
Last Name:GILMORE
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 1:624 INDIAN OAK LN UNIT 106
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91377-5665
Mailing Address - Country:US
Mailing Address - Phone:818-642-0433
Mailing Address - Fax:
Practice Address - Street 1:624 INDIAN OAK LN UNIT 106
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:CA
Practice Address - Zip Code:91377-5665
Practice Address - Country:US
Practice Address - Phone:818-642-0433
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-17
Last Update Date:2022-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11518843103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst