Provider Demographics
NPI:1083176895
Name:RODRIGUEZ, MARISSA NOEL
Entity Type:Individual
Prefix:MRS
First Name:MARISSA
Middle Name:NOEL
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10101 ZUNI PASS
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92503-5453
Mailing Address - Country:US
Mailing Address - Phone:951-522-1691
Mailing Address - Fax:
Practice Address - Street 1:3860 TYLER ST
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-3431
Practice Address - Country:US
Practice Address - Phone:951-523-8084
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-01
Last Update Date:2019-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11471225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist