Healthcare Provider Details

I. General information

NPI: 1205331857
Provider Name (Legal Business Name): MARISSA SUE GLORIA LLMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARISSA SUE PRATT

II. Dates (important events)

Enumeration Date: 03/27/2018
Last Update Date: 03/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 S CRAPO ST
MT PLEASANT MI
48858-2941
US

IV. Provider business mailing address

413 N 5TH ST
SHEPHERD MI
48883-9019
US

V. Phone/Fax

Practice location:
  • Phone: 989-772-5938
  • Fax: 989-775-7701
Mailing address:
  • Phone: 989-854-6783
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801102195
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: