Provider Demographics
NPI:1033436134
Name:CROOKS, MARISA LYNN (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:LYNN
Last Name:CROOKS
Suffix:
Gender:F
Credentials:MA, 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:PO BOX 2998
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32790-2998
Mailing Address - Country:US
Mailing Address - Phone:407-435-5652
Mailing Address - Fax:
Practice Address - Street 1:2125 PORTLIGHT DR
Practice Address - Street 2:201
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32814-6951
Practice Address - Country:US
Practice Address - Phone:407-435-5652
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-28
Last Update Date:2011-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA10273235Z00000X
FLSA 10273222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist