Provider Demographics
NPI:1336949262
Name:NISSEN, MALLYSSA ROSE
Entity type:Individual
Prefix:
First Name:MALLYSSA
Middle Name:ROSE
Last Name:NISSEN
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6740 PLAZA CURV NE
Mailing Address - Street 2:
Mailing Address - City:FRIDLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55432-4323
Mailing Address - Country:US
Mailing Address - Phone:612-709-2502
Mailing Address - Fax:
Practice Address - Street 1:6800 78TH AVE N
Practice Address - Street 2:
Practice Address - City:BROOKLYN PARK
Practice Address - State:MN
Practice Address - Zip Code:55445-2758
Practice Address - Country:US
Practice Address - Phone:612-314-0349
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-18
Last Update Date:2025-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN307186101YA0400X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)