Provider Demographics
NPI:1720668916
Name:VAN NOY, MARISSA J
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:J
Last Name:VAN NOY
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 1:238 E ROCKWOOD WAY
Mailing Address - Street 2:
Mailing Address - City:TOOELE
Mailing Address - State:UT
Mailing Address - Zip Code:84074-5573
Mailing Address - Country:US
Mailing Address - Phone:435-850-9708
Mailing Address - Fax:
Practice Address - Street 1:11620 S STATE ST STE 1404
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-7124
Practice Address - Country:US
Practice Address - Phone:801-508-4150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-12
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11991316-35021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty