Healthcare Provider Details

I. General information

NPI: 1952662033
Provider Name (Legal Business Name): MARISSA DWARICA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2012
Last Update Date: 06/19/2026
Certification Date: 06/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42-09 28TH ST 25N 11TH FL
LONG ISLAND CITY NY
11101
US

IV. Provider business mailing address

2152 RALPH AVE 346
BROOKLYN NY
11234-5406
US

V. Phone/Fax

Practice location:
  • Phone: 347-396-4794
  • Fax:
Mailing address:
  • Phone: 718-781-7654
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number402580
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: