Healthcare Provider Details

I. General information

NPI: 1962015610
Provider Name (Legal Business Name): MARISA NACHELLE RAYFORD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2020
Last Update Date: 05/09/2025
Certification Date: 05/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21100 SOUTHGATE PARK BLVD
MAPLE HEIGHTS OH
44137-3004
US

IV. Provider business mailing address

7232 JUSTIN WAY
MENTOR OH
44060-4881
US

V. Phone/Fax

Practice location:
  • Phone: 440-578-8200
  • Fax:
Mailing address:
  • Phone: 440-578-8200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number8202020
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberE.2505078
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: