Provider Demographics
NPI:1740647023
Name:GAMBLE, MARISSA JEAN (LMSW)
Entity type:Individual
Prefix:MRS
First Name:MARISSA
Middle Name:JEAN
Last Name:GAMBLE
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 2ND AVE STE 210
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29526-5205
Mailing Address - Country:US
Mailing Address - Phone:843-488-1615
Mailing Address - Fax:843-488-1616
Practice Address - Street 1:1300 2ND AVE STE 210
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-5205
Practice Address - Country:US
Practice Address - Phone:843-488-1615
Practice Address - Fax:843-488-1616
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-18
Last Update Date:2016-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC9610104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker