Provider Demographics
NPI:1174814206
Name:MARSELLO, MICHAEL J (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:MARSELLO
Suffix:
Gender:M
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1610 ROCKWOOD ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90026-5526
Mailing Address - Country:US
Mailing Address - Phone:413-658-8715
Mailing Address - Fax:
Practice Address - Street 1:1610 ROCKWOOD ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90026-5526
Practice Address - Country:US
Practice Address - Phone:413-658-8715
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-24
Last Update Date:2011-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18273235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist