Provider Demographics
NPI:1003243312
Name:YOUNG, MARISSA RAE (SLP)
Entity Type:Individual
Prefix:MS
First Name:MARISSA
Middle Name:RAE
Last Name:YOUNG
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:541 SW FIELDS AVE
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-4006
Mailing Address - Country:US
Mailing Address - Phone:561-729-6160
Mailing Address - Fax:
Practice Address - Street 1:4715 KIRBY LOOP RD
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34981-5345
Practice Address - Country:US
Practice Address - Phone:772-577-6964
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-01
Last Update Date:2021-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSI2224235Z00000X
FLSZ9191235Z00000X
FLSA18025235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL103979600Medicaid