Provider Demographics
NPI:1184971566
Name:MICKEL, MARISA K
Entity type:Individual
Prefix:MS
First Name:MARISA
Middle Name:K
Last Name:MICKEL
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 516
Mailing Address - Street 2:
Mailing Address - City:GARRISON
Mailing Address - State:NY
Mailing Address - Zip Code:10524-0516
Mailing Address - Country:US
Mailing Address - Phone:646-504-5254
Mailing Address - Fax:
Practice Address - Street 1:80 5TH AVE RM 903
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10011-7611
Practice Address - Country:US
Practice Address - Phone:212-633-9162
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-06
Last Update Date:2024-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0860631041C0700X
104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker