Provider Demographics
NPI:1902430291
Name:HOLLOMAN, MARISSA (LLMSW)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:HOLLOMAN
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 HURON AVE
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-3822
Mailing Address - Country:US
Mailing Address - Phone:810-990-1424
Mailing Address - Fax:
Practice Address - Street 1:222 HURON AVE
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-3822
Practice Address - Country:US
Practice Address - Phone:810-990-1424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-26
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801099543104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker