Provider Demographics
NPI:1215318894
Name:BRADY, MARISSA YVONNE
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:YVONNE
Last Name:BRADY
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 1:124 CARMEN LN STE A
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93458-7768
Mailing Address - Country:US
Mailing Address - Phone:805-348-1850
Mailing Address - Fax:
Practice Address - Street 1:208 NORTH RD SPC E
Practice Address - Street 2:
Practice Address - City:LOMPOC
Practice Address - State:CA
Practice Address - Zip Code:93436-2709
Practice Address - Country:US
Practice Address - Phone:805-757-1385
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-09
Last Update Date:2018-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
1316192149OtherTELECARE SM ACT