Healthcare Provider Details

I. General information

NPI: 1568720472
Provider Name (Legal Business Name): MARISSA ELIZABETH SHERMAN M.S., CMHC, PCI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MRS. MARISSA ELIZABETH MACIAS BIRD

II. Dates (important events)

Enumeration Date: 04/27/2012
Last Update Date: 04/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9140 S STATE ST SUITE 202
SANDY UT
84070-2684
US

IV. Provider business mailing address

4125 N CANYON RD
PROVO UT
84604-5015
US

V. Phone/Fax

Practice location:
  • Phone: 408-375-3311
  • Fax: 866-540-1490
Mailing address:
  • Phone: 408-375-3311
  • Fax: 866-540-1490

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number8173984-6004
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number8173984-6004
License Number StateUT
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number8173984-6004
License Number StateUT
# 4
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number8173984-6004
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: