Provider Demographics
NPI:1831741461
Name:FILLMORE, MARLYSSA RAE (PHD)
Entity type:Individual
Prefix:DR
First Name:MARLYSSA
Middle Name:RAE
Last Name:FILLMORE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4020 W GOELLER BLVD
Mailing Address - Street 2:ELLIE MENTAL HEALTH
Mailing Address - City:COLUMBUS
Mailing Address - State:IN
Mailing Address - Zip Code:47201-8499
Mailing Address - Country:US
Mailing Address - Phone:812-552-1499
Mailing Address - Fax:
Practice Address - Street 1:4980 HUNTERS RUN
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47201-8499
Practice Address - Country:US
Practice Address - Phone:812-552-1499
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-13
Last Update Date:2024-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20043326A103TC1900X, 103T00000X, 101YM0800X
IN10228724103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health