Provider Demographics
NPI:1124495924
Name:MYRES, MARISSA LIANA
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:LIANA
Last Name:MYRES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2054 LINDSAY RD
Mailing Address - Street 2:
Mailing Address - City:EVERSON
Mailing Address - State:WA
Mailing Address - Zip Code:98247-8218
Mailing Address - Country:US
Mailing Address - Phone:707-396-8859
Mailing Address - Fax:
Practice Address - Street 1:2054 LINDSAY RD
Practice Address - Street 2:
Practice Address - City:EVERSON
Practice Address - State:WA
Practice Address - Zip Code:98247-8218
Practice Address - Country:US
Practice Address - Phone:707-396-8859
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-27
Last Update Date:2015-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst