Provider Demographics
NPI:1265024897
Name:TADDA, MARISSA (DC)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:TADDA
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N96W18743 COUNTY LINE RD STOP E
Mailing Address - Street 2:
Mailing Address - City:MENOMONEE FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:53051-7100
Mailing Address - Country:US
Mailing Address - Phone:262-253-6779
Mailing Address - Fax:
Practice Address - Street 1:N96W18743 COUNTY LINE RD STOP E
Practice Address - Street 2:
Practice Address - City:MENOMONEE FALLS
Practice Address - State:WI
Practice Address - Zip Code:53051-7100
Practice Address - Country:US
Practice Address - Phone:262-253-6779
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-04
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4473-12111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor