Provider Demographics
NPI:1386082527
Name:PALANCE, MARISA LYNNE (MA)
Entity type:Individual
Prefix:
First Name:MARISA
Middle Name:LYNNE
Last Name:PALANCE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22451 VACRI LN
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48335-3851
Mailing Address - Country:US
Mailing Address - Phone:248-417-9121
Mailing Address - Fax:
Practice Address - Street 1:22451 VACRI LN
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48335-3851
Practice Address - Country:US
Practice Address - Phone:248-417-9121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-10
Last Update Date:2013-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301014602103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical