Provider Demographics
NPI:1962494872
Name:MARCHESSAULT, MAUREEN RIST (LCSW-R)
Entity Type:Individual
Prefix:MS
First Name:MAUREEN
Middle Name:RIST
Last Name:MARCHESSAULT
Suffix:
Gender:F
Credentials:LCSW-R
Other - Prefix:
Other - First Name:MAUREEN
Other - Middle Name:
Other - Last Name:RIST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW-R
Mailing Address - Street 1:21 ECHO VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:RED HOOK
Mailing Address - State:NY
Mailing Address - Zip Code:12571-2302
Mailing Address - Country:US
Mailing Address - Phone:845-758-5955
Mailing Address - Fax:
Practice Address - Street 1:21 ECHO VALLEY RD
Practice Address - Street 2:
Practice Address - City:RED HOOK
Practice Address - State:NY
Practice Address - Zip Code:12571-2302
Practice Address - Country:US
Practice Address - Phone:845-758-5955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-17
Last Update Date:2007-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY044391-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
044391-1OtherNYS LCSWR LICENSE