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General NPI Number Information
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NPI Number | 1124631171
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Entity Type | Individual
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Provider Name | MARISSA CARLSON LCSW
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Gender | Female
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Dates
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Enumeration Date | 08/28/2020
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Last Update Date | 10/30/2024
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Provider Practice Location Address
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Address Line | 201 N 8TH ST STE 4
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City | SAINT MARIES
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State | ID
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Zip | 83861-1869
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Country | US
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Telephone | 208-597-7639
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Fax | 208-717-9450
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Provider Business Mailing Address
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Address Line | 13498 E LAY LN
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City | MEDIMONT
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State | ID
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Zip | 83842-9775
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Country | US
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Telephone | 208-582-4024
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Fax | 208-717-9450
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | 39959
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License Number State | ID
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Taxonomy #2
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | LCSW-43558
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License Number State | ID
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