Provider Demographics
NPI:1922745835
Name:CHRISTEN-TUCCITTO, MARISSA MARIE
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:MARIE
Last Name:CHRISTEN-TUCCITTO
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 1:625 EMIL AVE
Mailing Address - Street 2:
Mailing Address - City:SHOREVIEW
Mailing Address - State:MN
Mailing Address - Zip Code:55126-4636
Mailing Address - Country:US
Mailing Address - Phone:651-417-9515
Mailing Address - Fax:
Practice Address - Street 1:10450 185TH ST W STE 100
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55044-6696
Practice Address - Country:US
Practice Address - Phone:612-509-1283
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-13
Last Update Date:2022-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNMCT0305Medicaid