Provider Demographics
NPI:1306655022
Name:FORT-CONRAD, MARISSA L (NCC, LPC)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:L
Last Name:FORT-CONRAD
Suffix:
Gender:F
Credentials:NCC, LPC
Other - Prefix:
Other - First Name:MARISSA
Other - Middle Name:L
Other - Last Name:FORT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NCC, PLPC
Mailing Address - Street 1:2712 E SADIE CT
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64801-4821
Mailing Address - Country:US
Mailing Address - Phone:417-621-5575
Mailing Address - Fax:
Practice Address - Street 1:1328 W BROADWAY ST STE 2
Practice Address - Street 2:
Practice Address - City:WEBB CITY
Practice Address - State:MO
Practice Address - Zip Code:64870-1620
Practice Address - Country:US
Practice Address - Phone:417-719-1407
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-07
Last Update Date:2025-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023005080101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health