Provider Demographics
NPI:1215431408
Name:JOHNSON, MARISSA M (LCSW)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:M
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MARISSA
Other - Middle Name:M
Other - Last Name:SEDILLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1795 JET WING DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80916-2332
Mailing Address - Country:US
Mailing Address - Phone:719-572-6100
Mailing Address - Fax:719-572-6089
Practice Address - Street 1:1795 JET WING DR
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80916-2332
Practice Address - Country:US
Practice Address - Phone:719-572-6100
Practice Address - Fax:719-572-6089
Is Sole Proprietor?:No
Enumeration Date:2018-03-21
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
COCSW.099300951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician