Healthcare Provider Details

I. General information

NPI: 1235823402
Provider Name (Legal Business Name): MARISSA SHEROUSE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2023
Last Update Date: 12/03/2024
Certification Date: 12/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

839 S CEDAR ST STE 100
MASON MI
48854-2063
US

IV. Provider business mailing address

8623 N WAYNE RD STE 310
WESTLAND MI
48185-1137
US

V. Phone/Fax

Practice location:
  • Phone: 517-507-0201
  • Fax: 517-969-3555
Mailing address:
  • Phone: 734-425-0636
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6451022956
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: