Provider Demographics
NPI:1457905176
Name:MITCHELL, MARISSA (LCSW)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:503 LEMOYNE AVE
Mailing Address - Street 2:
Mailing Address - City:ROMEOVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60446
Mailing Address - Country:US
Mailing Address - Phone:708-790-0469
Mailing Address - Fax:
Practice Address - Street 1:306 N LARKIN AVE
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-6698
Practice Address - Country:US
Practice Address - Phone:815-744-5560
Practice Address - Fax:708-843-0401
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-31
Last Update Date:2019-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty