Provider Demographics
NPI:1013227750
Name:WUNSCH, MARISSA LAUREN (MS CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:MARISSA
Middle Name:LAUREN
Last Name:WUNSCH
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 NE 175TH STREET
Mailing Address - Street 2:
Mailing Address - City:NORTH MIAMI BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:33162
Mailing Address - Country:US
Mailing Address - Phone:516-448-8215
Mailing Address - Fax:
Practice Address - Street 1:1111 NE 175TH STREET
Practice Address - Street 2:
Practice Address - City:NORTH MIAMI BEACH
Practice Address - State:NY
Practice Address - Zip Code:33162
Practice Address - Country:US
Practice Address - Phone:516-448-8215
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-15
Last Update Date:2010-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA10655235Z00000X
NY019002-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist