Provider Demographics
NPI:1245786227
Name:DOLETZKY, MARISSA MICHELLE
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:MICHELLE
Last Name:DOLETZKY
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 1:345 1/2 SIGSBEE ST
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49341-1029
Mailing Address - Country:US
Mailing Address - Phone:602-881-1753
Mailing Address - Fax:
Practice Address - Street 1:345 1/2 SIGSBEE ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:MI
Practice Address - Zip Code:49341-1029
Practice Address - Country:US
Practice Address - Phone:602-881-1753
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-30
Last Update Date:2019-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101005715235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist