Basic Information
| Provider Information | |||||||||
| NPI: | 1558700070 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROMANOVITCH | ||||||||
| FirstName: | MARISSA | ||||||||
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| Credential: | MSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 789 CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | DOVER | ||||||||
| State: | NH | ||||||||
| PostalCode: | 038202526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6037429200 | ||||||||
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| Practice Location | |||||||||
| Address1: | 15 OLD ROLLINSFORD RD | ||||||||
| Address2: | SUITE 302 | ||||||||
| City: | DOVER | ||||||||
| State: | NH | ||||||||
| PostalCode: | 038202868 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6037429200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2013 | ||||||||
| LastUpdateDate: | 01/27/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 1991 | NH | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 3106731 | 05 | NH | MEDICAID |