Provider Demographics
NPI:1770833055
Name:CHURCHILL, MARISSA MUNDY (MS, LPC, NCC)
Entity type:Individual
Prefix:MRS
First Name:MARISSA
Middle Name:MUNDY
Last Name:CHURCHILL
Suffix:
Gender:F
Credentials:MS, LPC, NCC
Other - Prefix:MISS
Other - First Name:MARISSA
Other - Middle Name:GAIL
Other - Last Name:MUNDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:23 LENOX POINTE NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30324-3172
Mailing Address - Country:US
Mailing Address - Phone:678-977-9313
Mailing Address - Fax:
Practice Address - Street 1:23 LENOX POINTE NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30324-3172
Practice Address - Country:US
Practice Address - Phone:678-977-9313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-14
Last Update Date:2016-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC003577101YM0800X
GALPC008452101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health