Healthcare Provider Details

I. General information

NPI: 1548926959
Provider Name (Legal Business Name): MARISSA STRADER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2021
Last Update Date: 11/10/2021
Certification Date: 11/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 MEMORIAL DR
PINEHURST NC
28374-8708
US

IV. Provider business mailing address

35 MEMORIAL DR
PINEHURST NC
28374-8708
US

V. Phone/Fax

Practice location:
  • Phone: 910-715-3376
  • Fax: 910-715-5391
Mailing address:
  • Phone: 910-715-3376
  • Fax: 910-715-5391

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC014413
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: