Provider Demographics
NPI:1457030850
Name:STEVENSON, MARISSA GRACE
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:GRACE
Last Name:STEVENSON
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 1:2748 S FERN CREEK AVE FL 32779
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-5539
Mailing Address - Country:US
Mailing Address - Phone:407-789-2673
Mailing Address - Fax:
Practice Address - Street 1:2748 S FERN CREEK AVE FL 32779
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-5539
Practice Address - Country:US
Practice Address - Phone:407-789-2673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-13
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL9437264171Medicaid