Provider Demographics
NPI:1902006307
Name:CLEMENTS, MARISSA J (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MARISSA
Middle Name:J
Last Name:CLEMENTS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1099 N COUNTRY RD STE L
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-1999
Mailing Address - Country:US
Mailing Address - Phone:631-626-4464
Mailing Address - Fax:
Practice Address - Street 1:1970 CLIFF VALLEY WAY NE
Practice Address - Street 2:SUITE 207
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30329-2428
Practice Address - Country:US
Practice Address - Phone:770-375-1244
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-23
Last Update Date:2008-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY003095103TC0700X
NY017582103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical