Provider Demographics
NPI:1265843064
Name:ANDERSON, MARISSA (OTR/L)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:228 WHIPPLE ST
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92058-7789
Mailing Address - Country:US
Mailing Address - Phone:619-602-3643
Mailing Address - Fax:
Practice Address - Street 1:11590 W BERNARDO CT STE 100
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92127-1624
Practice Address - Country:US
Practice Address - Phone:619-602-3643
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-14
Last Update Date:2015-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11691225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist