Provider Demographics
NPI:1295404564
Name:BERAZA, MARISSA N
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:N
Last Name:BERAZA
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 1:4010 W MICHIGAN AVE APT 20
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49006-5826
Mailing Address - Country:US
Mailing Address - Phone:269-674-9615
Mailing Address - Fax:
Practice Address - Street 1:4010 W MICHIGAN AVE APT 20
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49006-5826
Practice Address - Country:US
Practice Address - Phone:269-674-9615
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-09
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer