Provider Demographics
NPI:1780220962
Name:ROMO, MARISA I (MA, LPC, NCC)
Entity type:Individual
Prefix:
First Name:MARISA
Middle Name:I
Last Name:ROMO
Suffix:
Gender:F
Credentials:MA, LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 N MARIETTA PKWY NE APT C103
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-1495
Mailing Address - Country:US
Mailing Address - Phone:770-617-2730
Mailing Address - Fax:
Practice Address - Street 1:2957 CLAIRMON RD NE
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:GA
Practice Address - Zip Code:30329-4447
Practice Address - Country:US
Practice Address - Phone:470-747-3703
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-21
Last Update Date:2019-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXLPC009451101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health