Provider Demographics
NPI:1538272711
Name:RISSE, MARTIN A JR (LPC)
Entity type:Individual
Prefix:MR
First Name:MARTIN
Middle Name:A
Last Name:RISSE
Suffix:JR
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:101 E MAIN ST
Mailing Address - Street 2:SUITE 2100
Mailing Address - City:FESTUS
Mailing Address - State:MO
Mailing Address - Zip Code:63028-1904
Mailing Address - Country:US
Mailing Address - Phone:636-933-4870
Mailing Address - Fax:636-933-4875
Practice Address - Street 1:101 E MAIN ST
Practice Address - Street 2:SUITE 2100
Practice Address - City:FESTUS
Practice Address - State:MO
Practice Address - Zip Code:63028-1904
Practice Address - Country:US
Practice Address - Phone:636-933-4870
Practice Address - Fax:636-933-4875
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005038598101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional