Healthcare Provider Details

I. General information

NPI: 1124699731
Provider Name (Legal Business Name): MARISSA CHARLETT GRACE LPC, NCC, PMH-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2021
Last Update Date: 01/24/2024
Certification Date: 01/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

37 W FAIRMONT AVE STE 320
SAVANNAH GA
31406-3458
US

IV. Provider business mailing address

PO BOX 1431
POOLER GA
31322-1277
US

V. Phone/Fax

Practice location:
  • Phone: 850-217-4417
  • Fax:
Mailing address:
  • Phone: 850-217-4417
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC014137
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: