Healthcare Provider Details

I. General information

NPI: 1376394460
Provider Name (Legal Business Name): MARISSA JEANNE LECOUNT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2024
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2455 BENNETT VALLEY RD STE B209
SANTA ROSA CA
95404-5669
US

IV. Provider business mailing address

PO BOX 351
MONTE RIO CA
95462-0351
US

V. Phone/Fax

Practice location:
  • Phone: 707-224-8266
  • Fax:
Mailing address:
  • Phone: 650-208-4203
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: