Healthcare Provider Details

I. General information

NPI: 1992675730
Provider Name (Legal Business Name): MARISSA ELLEN FAULKNER MA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/07/2025
Last Update Date: 12/21/2025
Certification Date: 11/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 E ST UNIT A
SOUTH CHARLESTON WV
25303-1527
US

IV. Provider business mailing address

203 E ST UNIT A
SOUTH CHARLESTON WV
25303-1527
US

V. Phone/Fax

Practice location:
  • Phone: 304-919-5929
  • Fax:
Mailing address:
  • Phone: 304-919-5929
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: