Provider Demographics
NPI:1104525880
Name:WIDENER, MARISSA ANN (MC, LAC)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:ANN
Last Name:WIDENER
Suffix:
Gender:F
Credentials:MC, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 W ADAMS ST STE 514
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60606-5108
Mailing Address - Country:US
Mailing Address - Phone:312-578-9990
Mailing Address - Fax:312-275-7663
Practice Address - Street 1:101 N 1ST AVE STE 2310
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85003-1902
Practice Address - Country:US
Practice Address - Phone:888-661-2742
Practice Address - Fax:312-275-7663
Is Sole Proprietor?:No
Enumeration Date:2023-03-01
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-21828101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health