Provider Demographics
NPI:1750703898
Name:MOORE, MARISSA (LMHCA)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:LMHCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2429
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-8486
Mailing Address - Country:US
Mailing Address - Phone:206-466-5013
Mailing Address - Fax:206-721-6288
Practice Address - Street 1:15455 65TH AVE S
Practice Address - Street 2:
Practice Address - City:TUKWILA
Practice Address - State:WA
Practice Address - Zip Code:98188-2534
Practice Address - Country:US
Practice Address - Phone:206-721-5170
Practice Address - Fax:206-721-6288
Is Sole Proprietor?:No
Enumeration Date:2014-01-08
Last Update Date:2014-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMC60390441101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health