Provider Demographics
NPI:1427662113
Name:HOOSAC, MARISA (MS)
Entity type:Individual
Prefix:MRS
First Name:MARISA
Middle Name:
Last Name:HOOSAC
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 1:2001 W BLUE HERON BLVD
Mailing Address - Street 2:
Mailing Address - City:RIVIERA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33404-5003
Mailing Address - Country:US
Mailing Address - Phone:954-546-1279
Mailing Address - Fax:
Practice Address - Street 1:2001 W BLUE HERON BLVD
Practice Address - Street 2:
Practice Address - City:RIVIERA BEACH
Practice Address - State:FL
Practice Address - Zip Code:33404-5003
Practice Address - Country:US
Practice Address - Phone:561-841-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-01
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMT3188106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist