Provider Demographics
NPI:1255649877
Name:BOGATCH, MARISSA LYNN (SLP)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:LYNN
Last Name:BOGATCH
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:153 COMMONWEALTH ST
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN SQUARE
Mailing Address - State:NY
Mailing Address - Zip Code:11010-4217
Mailing Address - Country:US
Mailing Address - Phone:516-328-0029
Mailing Address - Fax:
Practice Address - Street 1:153 COMMONWEALTH ST
Practice Address - Street 2:
Practice Address - City:FRANKLIN SQUARE
Practice Address - State:NY
Practice Address - Zip Code:11010-4217
Practice Address - Country:US
Practice Address - Phone:516-328-0029
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-16
Last Update Date:2010-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019218235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist