Provider Demographics
NPI:1740633296
Name:KUSHNER, MARISSA (PHD)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:KUSHNER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12791 WORLD PLAZA LN
Mailing Address - Street 2:BLDG 89
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-3989
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12791 WORLD PLAZA LN
Practice Address - Street 2:BLDG 89
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-3989
Practice Address - Country:US
Practice Address - Phone:239-247-1756
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-20
Last Update Date:2016-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD05695103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent