Provider Demographics
NPI:1124699731
Name:GRACE, MARISSA CHARLETT (LPC, NCC, PMH-C)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:CHARLETT
Last Name:GRACE
Suffix:
Gender:F
Credentials:LPC, NCC, PMH-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1431
Mailing Address - Street 2:
Mailing Address - City:POOLER
Mailing Address - State:GA
Mailing Address - Zip Code:31322-1277
Mailing Address - Country:US
Mailing Address - Phone:850-217-4417
Mailing Address - Fax:
Practice Address - Street 1:37 W FAIRMONT AVE STE 320
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31406-3458
Practice Address - Country:US
Practice Address - Phone:850-217-4417
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-06
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
374J00000X
GALPC014137101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No374J00000XNursing Service Related ProvidersDoulaGroup - Single Specialty