Basic Information
| Provider Information | |||||||||
| NPI: | 1699843482 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SPANN | ||||||||
| FirstName: | MARISA | ||||||||
| MiddleName: | NICOLE | ||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9805 | ||||||||
| Address2: | 300 GEORGE ST 6TH FLR | ||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065360805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037857998 | ||||||||
| FaxNumber: | 2037856414 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 HOWARD AVE | ||||||||
| Address2: | YALE PHYSICIANS BLDG | ||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065191369 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037852140 | ||||||||
| FaxNumber: | 2037856414 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2006 | ||||||||
| LastUpdateDate: | 04/30/2018 | ||||||||
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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 | 103TC0700X | 002730 | CT | N | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC0700X | 019064 | NY | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.