Provider Demographics
NPI:1831633049
Name:MARVIN, MARISA (LCSW)
Entity type:Individual
Prefix:
First Name:MARISA
Middle Name:
Last Name:MARVIN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4150 E SIERRA MADRE AVE
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85296-3084
Mailing Address - Country:US
Mailing Address - Phone:480-284-3271
Mailing Address - Fax:
Practice Address - Street 1:1255 W BASELINE RD STE B258
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85202-5820
Practice Address - Country:US
Practice Address - Phone:480-284-3271
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-06
Last Update Date:2016-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW-159351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical