Provider Demographics
NPI:1669807095
Name:CARRAWAY, MARISSA ANNE ERRICKSON (MA, PHD)
Entity type:Individual
Prefix:MRS
First Name:MARISSA
Middle Name:ANNE ERRICKSON
Last Name:CARRAWAY
Suffix:
Gender:F
Credentials:MA, PHD
Other - Prefix:
Other - First Name:MARISSA
Other - Middle Name:
Other - Last Name:ERRICKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 751069
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1069
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:101 HEART DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-8982
Practice Address - Country:US
Practice Address - Phone:252-744-4611
Practice Address - Fax:252-744-3201
Is Sole Proprietor?:No
Enumeration Date:2013-09-04
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NC4866103T00000X
TN103TH0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC19EXBOtherBCBS NC
NC1669807095Medicaid
NC1669807095Medicaid