Provider Demographics
NPI:1841765732
Name:PETERSON, MARISSA
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:PETERSON
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 1:232 E 82ND ST
Mailing Address - Street 2:
Mailing Address - City:NEWAYGO
Mailing Address - State:MI
Mailing Address - Zip Code:49337-9631
Mailing Address - Country:US
Mailing Address - Phone:231-652-1780
Mailing Address - Fax:
Practice Address - Street 1:2723 S STATE ST STE 150
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-6188
Practice Address - Country:US
Practice Address - Phone:844-263-1613
Practice Address - Fax:844-263-1612
Is Sole Proprietor?:No
Enumeration Date:2018-10-08
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker