Provider Demographics
NPI:1083116412
Name:MELTZER, MARISSA CARLY (MA)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:CARLY
Last Name:MELTZER
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:645 TAMALPAIS DR STE B
Mailing Address - Street 2:
Mailing Address - City:CORTE MADERA
Mailing Address - State:CA
Mailing Address - Zip Code:94925-1613
Mailing Address - Country:US
Mailing Address - Phone:415-924-2444
Mailing Address - Fax:415-924-2442
Practice Address - Street 1:645 TAMALPAIS DR STE B
Practice Address - Street 2:
Practice Address - City:CORTE MADERA
Practice Address - State:CA
Practice Address - Zip Code:94925-1613
Practice Address - Country:US
Practice Address - Phone:415-924-2444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-01
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25549235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA94-3314238Medicaid