Provider Demographics
NPI:1467152413
Name:ILLINGWORTH, MARISSA L (CRM PSS)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:L
Last Name:ILLINGWORTH
Suffix:
Gender:F
Credentials:CRM PSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5189 DOME ROCK CT SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97306-2550
Mailing Address - Country:US
Mailing Address - Phone:503-851-6279
Mailing Address - Fax:
Practice Address - Street 1:2045 SILVERTON RD NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-0100
Practice Address - Country:US
Practice Address - Phone:503-576-4660
Practice Address - Fax:503-361-2688
Is Sole Proprietor?:No
Enumeration Date:2023-03-08
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORT-23-2885101YA0400X
OR22-CRM--1462175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORT-23-2885OtherMHACBO