Provider Demographics
NPI:1740520865
Name:WHITFORD, MARISSA BLAIR (LLPC)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:BLAIR
Last Name:WHITFORD
Suffix:
Gender:F
Credentials:LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2888 E LONG LAKE RD
Mailing Address - Street 2:SUITE # 170
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48085-3793
Mailing Address - Country:US
Mailing Address - Phone:248-462-9349
Mailing Address - Fax:
Practice Address - Street 1:2888 E LONG LAKE RD
Practice Address - Street 2:SUITE # 170
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48085-3793
Practice Address - Country:US
Practice Address - Phone:248-462-9349
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-26
Last Update Date:2013-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401011977101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional