Provider Demographics
NPI:1043580376
Name:LOBOSCO, MARISSA GORDETSKY (MS, CCC-SLP TSSLD)
Entity Type:Individual
Prefix:MS
First Name:MARISSA
Middle Name:GORDETSKY
Last Name:LOBOSCO
Suffix:
Gender:F
Credentials:MS, CCC-SLP TSSLD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 DOMESSINA LN APT D7
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:NJ
Mailing Address - Zip Code:07006-4854
Mailing Address - Country:US
Mailing Address - Phone:917-355-8343
Mailing Address - Fax:
Practice Address - Street 1:60 MADISON AVE FL 8
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-1676
Practice Address - Country:US
Practice Address - Phone:212-684-0099
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-03
Last Update Date:2012-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021543-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist