Provider Demographics
NPI:1306193875
Name:HINICH, MARISSA (PTA)
Entity Type:Individual
Prefix:MS
First Name:MARISSA
Middle Name:
Last Name:HINICH
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11904 W NORTH AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-2062
Mailing Address - Country:US
Mailing Address - Phone:414-453-8616
Mailing Address - Fax:414-453-6150
Practice Address - Street 1:11904 W NORTH AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-2062
Practice Address - Country:US
Practice Address - Phone:414-453-8616
Practice Address - Fax:414-453-6150
Is Sole Proprietor?:No
Enumeration Date:2012-08-14
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1682-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant