Provider Demographics
NPI:1114670288
Name:COLON, MARISSA (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:COLON
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2650 W SEGERSTROM AVE UNIT C
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92704-6556
Mailing Address - Country:US
Mailing Address - Phone:510-459-7378
Mailing Address - Fax:
Practice Address - Street 1:2650 W SEGERSTROM AVE UNIT C
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92704-6556
Practice Address - Country:US
Practice Address - Phone:510-459-7378
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-30
Last Update Date:2022-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP31332235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist