Provider Demographics
NPI:1013747146
Name:WILSON, MARISSA C
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:C
Last Name:WILSON
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 1:7 DOMINION CIR
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75033-4748
Mailing Address - Country:US
Mailing Address - Phone:469-514-8478
Mailing Address - Fax:
Practice Address - Street 1:905 ROBERTS CUT OFF RD
Practice Address - Street 2:
Practice Address - City:RIVER OAKS
Practice Address - State:TX
Practice Address - Zip Code:76114-2825
Practice Address - Country:US
Practice Address - Phone:281-894-1422
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-05
Last Update Date:2024-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician