Individual
MARISSA LEE LODGE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
8616 NORTHERN AVE, ROCKFORD, IL 61107-5309
(815) 332-8003
Mailing address
1021 N MULFORD RD, ROCKFORD, IL 61107-3877
Taxonomy
Speciality
Code
Description
License number
State
101Y00000X
Counselor
Primary
—
—
106S00000X
Behavior Technician
—
—
Other
Enumeration date
04/17/2017
Last updated
08/03/2018
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