Provider Demographics
NPI:1457135881
Name:CARGILL, MARISA
Entity Type:Individual
Prefix:DR
First Name:MARISA
Middle Name:
Last Name:CARGILL
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 1:674 LILAC LN
Mailing Address - Street 2:
Mailing Address - City:COPLEY
Mailing Address - State:OH
Mailing Address - Zip Code:44321-2896
Mailing Address - Country:US
Mailing Address - Phone:330-715-2141
Mailing Address - Fax:
Practice Address - Street 1:3443 MEDINA RD STE 101C
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256-5965
Practice Address - Country:US
Practice Address - Phone:216-285-0304
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-24
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE.2202900-SUPV101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional