Provider Demographics
NPI:1326773623
Name:MADDALENA, MARISSA (OTD, OTR/L)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:MADDALENA
Suffix:
Gender:F
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:MARISSA
Other - Middle Name:
Other - Last Name:MADDALENA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OTD, OTR/L
Mailing Address - Street 1:608 SANTA CLARA AVE APT 4
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:CA
Mailing Address - Zip Code:90291-3464
Mailing Address - Country:US
Mailing Address - Phone:540-542-9625
Mailing Address - Fax:
Practice Address - Street 1:1932 14TH ST
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-4605
Practice Address - Country:US
Practice Address - Phone:310-344-2276
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-20
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23494225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics