Basic Information
| Provider Information | |||||||||
| NPI: | 1366861551 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAPLE | ||||||||
| FirstName: | MARISSA | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PELHAM | ||||||||
| OtherFirstName: | MARISSA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 141 E MAIN ST FL 4 | ||||||||
| Address2: | |||||||||
| City: | WATERBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067022310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035749000 | ||||||||
| FaxNumber: | 2035749006 | ||||||||
| Practice Location | |||||||||
| Address1: | 141 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | WATERBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067022310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035749000 | ||||||||
| FaxNumber: | 2035749006 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/15/2014 | ||||||||
| LastUpdateDate: | 03/23/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183700000X | PTN.0011947 | CT | N | Pharmacy Service Providers | Pharmacy Technician | 1041C0700X | 9267 | CT | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | D339209 | 01 | CT | VALUE OPTIONS/BEACON HEALTH STRATEGIES | OTHER | 008060347 | 05 | CT | MEDICAID | 060669107 | 01 | CT | UBH-UNITED HEALTHCARE WELLMORE GRP/FACILITY | OTHER | 13559521 | 01 | CT | CAQH | OTHER | 060669107 | 01 | CT | UBH-CONNECTICARE WELLMORE GRP/FACILITY | OTHER | PENDING | 01 | CT | MHN TRICARE NORTH | OTHER | PENDING | 01 | CT | AETNA BEHAVIORAL HEALTH | OTHER | PENDING | 01 | CT | CIGNA BEHAVIORAL HEALTH | OTHER | 060669107 | 01 | CT | ANTHEM BCBS OF CT WELLMORE GRP/FACILITY | OTHER | PENDING | 01 | CT | MHN MANAGED HEALTH NETWORK | OTHER | 060669107 | 01 | CT | UNITED BEHAVIORAL HEALTH WELLMORE GRP/FACILITY | OTHER | 060669107 | 01 | CT | UBH OXFORD/FREEDOM/LIBERTY WELLMORE GRP/FACILITY | OTHER |