Provider Demographics
NPI:1417429366
Name:YOUNG, MARISA CHRISTINE
Entity type:Individual
Prefix:
First Name:MARISA
Middle Name:CHRISTINE
Last Name:YOUNG
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 1:23 SHERMANS RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:VA
Mailing Address - Zip Code:22554-6817
Mailing Address - Country:US
Mailing Address - Phone:509-362-2396
Mailing Address - Fax:
Practice Address - Street 1:1651 OLD MEADOW RD
Practice Address - Street 2:STE 600
Practice Address - City:MC LEAN
Practice Address - State:VA
Practice Address - Zip Code:22102-4389
Practice Address - Country:US
Practice Address - Phone:703-564-1639
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-17
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician