Provider Demographics
NPI:1114687787
Name:BUCKLEY, MARISSA (MS, RD, LD)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:BUCKLEY
Suffix:
Gender:F
Credentials:MS, RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 W DEAN KEETON ST
Mailing Address - Street 2:CAMPUS MAIL A3900
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78712
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 W DEAN KEETON ST
Practice Address - Street 2:CAMPUS MAIL A3900
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78712
Practice Address - Country:US
Practice Address - Phone:512-471-4955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-23
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered