Provider Demographics
NPI:1588869739
Name:PENA, MARISSA ROSE (LCSW)
Entity type:Individual
Prefix:MRS
First Name:MARISSA
Middle Name:ROSE
Last Name:PENA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3922 OLD COLUMBIA PIKE
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21043-5411
Mailing Address - Country:US
Mailing Address - Phone:410-310-4639
Mailing Address - Fax:
Practice Address - Street 1:1060 W PERIMETER RD
Practice Address - Street 2:
Practice Address - City:JB ANDREWS
Practice Address - State:MD
Practice Address - Zip Code:20762-6602
Practice Address - Country:US
Practice Address - Phone:240-857-7186
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-18
Last Update Date:2021-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11716101YA0400X
MD270771041C0700X
NMC-073021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDLCSW-COtherCLINICAL SOCIAL WORKER
TXLCDCOtherLICENSED CHEMICAL DEPENDENCY COUNSELOR
NMLCSWOtherCLINICAL SOCIAL WORK