Provider Demographics
NPI:1447953047
Name:LENNON, MARISSA NICOLE (CASAC-T)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:NICOLE
Last Name:LENNON
Suffix:
Gender:F
Credentials:CASAC-T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 CHERRY LN
Mailing Address - Street 2:
Mailing Address - City:HICKSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11801-6232
Mailing Address - Country:US
Mailing Address - Phone:516-733-7040
Mailing Address - Fax:
Practice Address - Street 1:31 E MONTAUK HWY
Practice Address - Street 2:
Practice Address - City:HAMPTON BAYS
Practice Address - State:NY
Practice Address - Zip Code:11946-1816
Practice Address - Country:US
Practice Address - Phone:516-733-7040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-23
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health