Provider Demographics
NPI:1245645100
Name:BINGHAM, MARISSA (MS)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:BINGHAM
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 SIERRA ROSA
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87507-7602
Mailing Address - Country:US
Mailing Address - Phone:541-870-9374
Mailing Address - Fax:
Practice Address - Street 1:1025 HERMOSA DR SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-4312
Practice Address - Country:US
Practice Address - Phone:505-237-0061
Practice Address - Fax:505-237-0068
Is Sole Proprietor?:No
Enumeration Date:2014-06-30
Last Update Date:2015-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 106H00000X
NMT-0177501106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health