Provider Demographics
NPI:1336864206
Name:CAUDILL, MARISSA B
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:B
Last Name:CAUDILL
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 1:207D COLEGATE DR
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:OH
Mailing Address - Zip Code:45750-2363
Mailing Address - Country:US
Mailing Address - Phone:740-376-0930
Mailing Address - Fax:740-376-0933
Practice Address - Street 1:207D COLEGATE DR
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:OH
Practice Address - Zip Code:45750-2363
Practice Address - Country:US
Practice Address - Phone:740-376-0930
Practice Address - Fax:740-376-0933
Is Sole Proprietor?:No
Enumeration Date:2022-10-04
Last Update Date:2022-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.1802799104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker