Provider Demographics
NPI:1699843482
Name:SPANN, MARISA NICOLE (PHD)
Entity type:Individual
Prefix:
First Name:MARISA
Middle Name:NICOLE
Last Name:SPANN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9805
Mailing Address - Street 2:300 GEORGE ST 6TH FLR
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06536-0805
Mailing Address - Country:US
Mailing Address - Phone:203-785-7998
Mailing Address - Fax:203-785-6414
Practice Address - Street 1:800 HOWARD AVE
Practice Address - Street 2:YALE PHYSICIANS BLDG
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06519-1369
Practice Address - Country:US
Practice Address - Phone:203-785-2140
Practice Address - Fax:203-785-6414
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2018-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002730103TC0700X
NY019064103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical