Provider Demographics
NPI:1003944091
Name:LOVE, MARISA (ATC OTRL)
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:
Last Name:LOVE
Suffix:
Gender:F
Credentials:ATC OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2612 NORTH AVE
Mailing Address - Street 2:UNIT D 2
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06604-2300
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1931 BLACK ROCK TPKE
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06825-3506
Practice Address - Country:US
Practice Address - Phone:203-384-8681
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
CT002257225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Not Answered225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics