Provider Demographics
NPI:1114584521
Name:STOCKSTAD, MARISSA
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:STOCKSTAD
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 1:163 LIBBEY INDUSTRIAL PKWY STE 302
Mailing Address - Street 2:
Mailing Address - City:WEYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02189-3137
Mailing Address - Country:US
Mailing Address - Phone:781-335-6663
Mailing Address - Fax:
Practice Address - Street 1:163 LIBBEY INDUSTRIAL PKWY STE 302
Practice Address - Street 2:
Practice Address - City:WEYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02189-3137
Practice Address - Country:US
Practice Address - Phone:781-335-6663
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-21
Last Update Date:2019-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA77245235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist