Provider Demographics
NPI:1043920770
Name:GONZALEZ, MARISSA PADILLA (OTR/L)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:PADILLA
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 INGLE PL
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22304-7601
Mailing Address - Country:US
Mailing Address - Phone:619-384-8451
Mailing Address - Fax:
Practice Address - Street 1:1025 CONNECTICUT AVE NW STE 417
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20036-5458
Practice Address - Country:US
Practice Address - Phone:202-528-7223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-05
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCOT210002092225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist