Provider Demographics
NPI:1831925312
Name:GEDDES, MARISA
Entity type:Individual
Prefix:
First Name:MARISA
Middle Name:
Last Name:GEDDES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:366 WALNUT HILL RD
Mailing Address - Street 2:
Mailing Address - City:THOMASTON
Mailing Address - State:CT
Mailing Address - Zip Code:06787-1145
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:366 WALNUT HILL RD
Practice Address - Street 2:
Practice Address - City:THOMASTON
Practice Address - State:CT
Practice Address - Zip Code:06787-1145
Practice Address - Country:US
Practice Address - Phone:203-206-3573
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-11
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1933103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst