Provider Demographics
NPI:1184449621
Name:GOLDMAN, MARISSA L (LCSW)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:L
Last Name:GOLDMAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6852 MAGOUN AVE
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:IN
Mailing Address - Zip Code:46324-1714
Mailing Address - Country:US
Mailing Address - Phone:219-298-0247
Mailing Address - Fax:
Practice Address - Street 1:18141 DIXIE HWY STE 202
Practice Address - Street 2:
Practice Address - City:HOMEWOOD
Practice Address - State:IL
Practice Address - Zip Code:60430-2243
Practice Address - Country:US
Practice Address - Phone:708-956-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-19
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0281941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical