Provider Demographics
NPI:1093448136
Name:BALL, MARISSA JANE (CDCA)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:JANE
Last Name:BALL
Suffix:
Gender:F
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 W STROOP RD
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45439-2041
Mailing Address - Country:US
Mailing Address - Phone:937-203-8115
Mailing Address - Fax:
Practice Address - Street 1:36 N DETROIT ST
Practice Address - Street 2:
Practice Address - City:XENIA
Practice Address - State:OH
Practice Address - Zip Code:45385-2909
Practice Address - Country:US
Practice Address - Phone:513-892-4673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-06
Last Update Date:2024-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLCDCII.162037101YA0400X
106S00000X, 171M00000X
OHCDCA.181955101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No171M00000XOther Service ProvidersCase Manager/Care Coordinator