Provider Demographics
NPI:1942737515
Name:VANCE, MARRISSA
Entity type:Individual
Prefix:
First Name:MARRISSA
Middle Name:
Last Name:VANCE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:265 SAN JACINTO RIVER RD STE 107
Mailing Address - Street 2:
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92530-4400
Mailing Address - Country:US
Mailing Address - Phone:951-674-9243
Mailing Address - Fax:951-674-9635
Practice Address - Street 1:265 SAN JACINTO RIVER RD STE 107
Practice Address - Street 2:
Practice Address - City:LAKE ELSINORE
Practice Address - State:CA
Practice Address - Zip Code:92530-4400
Practice Address - Country:US
Practice Address - Phone:951-674-9243
Practice Address - Fax:951-674-9635
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-15
Last Update Date:2017-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty