Provider Demographics
NPI:1235764960
Name:SWANSON, MARISSA (BCABA, CF-SLP)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:SWANSON
Suffix:
Gender:F
Credentials:BCABA, CF-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 LAURENCE AVE STE E
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49202-2980
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1001 LAURENCE AVE STE E
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49202-2980
Practice Address - Country:US
Practice Address - Phone:517-750-4777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-03
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI106E00000X
MI715001797235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst