Provider Demographics
NPI:1134555840
Name:BADGLEY, MARISA M (MS, LPCC-S , LICDC)
Entity type:Individual
Prefix:
First Name:MARISA
Middle Name:M
Last Name:BADGLEY
Suffix:
Gender:F
Credentials:MS, LPCC-S , LICDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5335 FAR HILLS AVE STE 211
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45429-2317
Mailing Address - Country:US
Mailing Address - Phone:937-221-8434
Mailing Address - Fax:
Practice Address - Street 1:5335 FAR HILLS AVE STE 211
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45429-2317
Practice Address - Country:US
Practice Address - Phone:937-221-8434
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-26
Last Update Date:2019-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH151092101YA0400X
OHE.1200246101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0226088Medicaid