Provider Demographics
NPI:1336654409
Name:EASTER, MARISA THOMAS
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:THOMAS
Last Name:EASTER
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 1:22 RAYMOND DR
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666-2642
Mailing Address - Country:US
Mailing Address - Phone:757-825-1191
Mailing Address - Fax:
Practice Address - Street 1:1406 TODDS LN
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-2945
Practice Address - Country:US
Practice Address - Phone:757-825-4627
Practice Address - Fax:757-896-6731
Is Sole Proprietor?:No
Enumeration Date:2017-12-11
Last Update Date:2017-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202002096235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist