Provider Demographics
NPI:1427648740
Name:KIMMEL, MARISSA NICOLE (MSED)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:NICOLE
Last Name:KIMMEL
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1307 S HANCOCK ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19147-6118
Mailing Address - Country:US
Mailing Address - Phone:856-979-1493
Mailing Address - Fax:
Practice Address - Street 1:288 LANCASTER AVE STE 1
Practice Address - Street 2:
Practice Address - City:FRAZER
Practice Address - State:PA
Practice Address - Zip Code:19355-1800
Practice Address - Country:US
Practice Address - Phone:856-979-1493
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-20
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health