Provider Demographics
NPI:1952127367
Name:PETERSEN, MARRISSA MARIE
Entity type:Individual
Prefix:
First Name:MARRISSA
Middle Name:MARIE
Last Name:PETERSEN
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 1:12110 PORT GRACE BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:LA VISTA
Mailing Address - State:NE
Mailing Address - Zip Code:68128-3190
Mailing Address - Country:US
Mailing Address - Phone:402-325-1290
Mailing Address - Fax:
Practice Address - Street 1:12110 PORT GRACE BLVD STE 101
Practice Address - Street 2:
Practice Address - City:LA VISTA
Practice Address - State:NE
Practice Address - Zip Code:68128-3190
Practice Address - Country:US
Practice Address - Phone:402-325-1290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-02
Last Update Date:2025-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NEP-2244101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)