Provider Demographics
NPI:1992354963
Name:MARTIN, MARISA (LPC, LMHC)
Entity type:Individual
Prefix:
First Name:MARISA
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LPC, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4115 COUNTRY CLUB DR NE
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98422-4621
Mailing Address - Country:US
Mailing Address - Phone:206-661-0599
Mailing Address - Fax:
Practice Address - Street 1:13925 INTERURBAN AVE S STE 120
Practice Address - Street 2:
Practice Address - City:TUKWILA
Practice Address - State:WA
Practice Address - Zip Code:98168-5718
Practice Address - Country:US
Practice Address - Phone:206-580-7275
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-11
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC6883101YP2500X
WALH61339219101YM0800X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional