Healthcare Provider Details

I. General information

NPI: 1659205904
Provider Name (Legal Business Name): MARISSA LEE WAFFORD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2026
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 MEADOW DR STE A
MOUNT GILEAD OH
43338-1389
US

IV. Provider business mailing address

16 W LONG ST
COLUMBUS OH
43215-2815
US

V. Phone/Fax

Practice location:
  • Phone: 419-949-2000
  • Fax: 419-751-7322
Mailing address:
  • Phone: 614-225-0990
  • Fax: 614-225-0991

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: