Provider Demographics
NPI:1194498816
Name:MIARS, MARISSA (LGPC)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:MIARS
Suffix:
Gender:F
Credentials:LGPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1413 RACE ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21230-4412
Mailing Address - Country:US
Mailing Address - Phone:269-303-2130
Mailing Address - Fax:
Practice Address - Street 1:5022 CAMPBELL BLVD # 4969
Practice Address - Street 2:
Practice Address - City:NOTTINGHAM
Practice Address - State:MD
Practice Address - Zip Code:21236-4969
Practice Address - Country:US
Practice Address - Phone:443-442-1568
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-28
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP11736101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health