Provider Demographics
NPI:1609666221
Name:KENDALL, MARISSA
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:KENDALL
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 SCEPTER CT NE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-3194
Mailing Address - Country:US
Mailing Address - Phone:503-884-5672
Mailing Address - Fax:
Practice Address - Street 1:5520 S MACADAM AVE STE 210
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3747
Practice Address - Country:US
Practice Address - Phone:503-893-4671
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-07
Last Update Date:2025-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORR11104101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health