Healthcare Provider Details

I. General information

NPI: 1407453939
Provider Name (Legal Business Name): MARISSA BLOCK LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2020
Last Update Date: 06/13/2023
Certification Date: 06/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 E JOPPA RD
TOWSON MD
21286-3150
US

IV. Provider business mailing address

502 CHARLES STREET AVE
TOWSON MD
21204-4206
US

V. Phone/Fax

Practice location:
  • Phone: 443-300-6905
  • Fax: 443-233-0231
Mailing address:
  • Phone: 636-399-6160
  • Fax: 443-233-0231

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number
License Number State

VIII. Authorized Official

Name: MARISSA BLOCK
Title or Position: CEO/FOUNDER
Credential:
Phone: 443-300-6905