Provider Demographics
NPI:1275226953
Name:BUMGARNER, MARISSA A (RBT)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:A
Last Name:BUMGARNER
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2164
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73083-2164
Mailing Address - Country:US
Mailing Address - Phone:405-216-3391
Mailing Address - Fax:405-216-3391
Practice Address - Street 1:409 S FRETZ AVE STE D
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73003-5570
Practice Address - Country:US
Practice Address - Phone:405-216-3391
Practice Address - Fax:405-216-3391
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-30
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKRBT-23-274722106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician