Healthcare Provider Details

I. General information

NPI: 1063832343
Provider Name (Legal Business Name): MARISSA L MASCORRO PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2014
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2999 N 44TH ST STE 415
PHOENIX AZ
85018-7251
US

IV. Provider business mailing address

2999 N 44TH ST STE 415
PHOENIX AZ
85018-7251
US

V. Phone/Fax

Practice location:
  • Phone: 602-675-0335
  • Fax: 602-865-8089
Mailing address:
  • Phone: 602-675-0335
  • Fax: 602-865-8089

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLAC-13710
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC-17047
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY-005980
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: