Healthcare Provider Details

I. General information

NPI: 1336574656
Provider Name (Legal Business Name): MARISSA K FRESON MSED, LMFTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2013
Last Update Date: 04/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 LAKE AVE
FORT WAYNE IN
46805-5407
US

IV. Provider business mailing address

2525 LAKE AVE
FORT WAYNE IN
46805-5407
US

V. Phone/Fax

Practice location:
  • Phone: 260-484-4153
  • Fax: 260-496-5996
Mailing address:
  • Phone: 260-484-4153
  • Fax: 260-496-5996

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: