Provider Demographics
NPI:1386243012
Name:DELVALLE, MARISSA CHRISTINA
Entity type:Individual
Prefix:MS
First Name:MARISSA
Middle Name:CHRISTINA
Last Name:DELVALLE
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 1:403 CHESTER ST
Mailing Address - Street 2:
Mailing Address - City:UNIONDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11553-2003
Mailing Address - Country:US
Mailing Address - Phone:929-300-4814
Mailing Address - Fax:
Practice Address - Street 1:10470 QUEENS BLVD STE 200
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-3694
Practice Address - Country:US
Practice Address - Phone:718-275-6010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-23
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP108269101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health