Provider Demographics
NPI:1386529519
Name:KOMAR, MARISSA GABRIELLE
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:GABRIELLE
Last Name:KOMAR
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1820 85TH ST
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53143-6426
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1820 85TH ST
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53143-6426
Practice Address - Country:US
Practice Address - Phone:262-371-5030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-07
Last Update Date:2025-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician