Provider Demographics
NPI:1205457058
Name:TOLERO, MARISSA
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:TOLERO
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 1:70 CHRISTOPHER COLUMBUS DR APT 3709
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07302-7063
Mailing Address - Country:US
Mailing Address - Phone:510-367-2031
Mailing Address - Fax:
Practice Address - Street 1:30 E END AVE APT 1C
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10028-7097
Practice Address - Country:US
Practice Address - Phone:917-670-9780
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-04
Last Update Date:2020-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009688101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty