Provider Demographics
NPI:1124355631
Name:SHANNON, MARISSA CATHERINE (MFT)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:CATHERINE
Last Name:SHANNON
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1909 MARGUERITE AVE
Mailing Address - Street 2:
Mailing Address - City:PLEASANT HILL
Mailing Address - State:CA
Mailing Address - Zip Code:94523-2717
Mailing Address - Country:US
Mailing Address - Phone:510-856-7476
Mailing Address - Fax:
Practice Address - Street 1:1460 MARIA LN STE 300
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94596-5314
Practice Address - Country:US
Practice Address - Phone:925-644-0400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-05
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF 60402106H00000X
CALMFT53746106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist