Provider Demographics
NPI:1992194039
Name:MANSELL, MARISA
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:
Last Name:MANSELL
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:PO BOX 205
Mailing Address - Street 2:
Mailing Address - City:STRINGTOWN
Mailing Address - State:OK
Mailing Address - Zip Code:74569-0205
Mailing Address - Country:US
Mailing Address - Phone:580-513-1622
Mailing Address - Fax:
Practice Address - Street 1:1410 S GIN RD
Practice Address - Street 2:
Practice Address - City:ATOKA
Practice Address - State:OK
Practice Address - Zip Code:74525-7348
Practice Address - Country:US
Practice Address - Phone:580-889-3399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-13
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health