Provider Demographics
NPI:1114368578
Name:SEABLOM, MARISSA ANN (DPT)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:ANN
Last Name:SEABLOM
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:789 PINE ST
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401-4933
Mailing Address - Country:US
Mailing Address - Phone:802-264-1052
Mailing Address - Fax:802-264-1053
Practice Address - Street 1:812 EXCHANGE ST
Practice Address - Street 2:
Practice Address - City:MIDDLEBURY
Practice Address - State:VT
Practice Address - Zip Code:05753-1555
Practice Address - Country:US
Practice Address - Phone:802-388-3991
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-15
Last Update Date:2013-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT040.0094906225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist