Provider Demographics
NPI:1366693533
Name:KING, MARISSA ANN (MCD, CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:MARISSA
Middle Name:ANN
Last Name:KING
Suffix:
Gender:F
Credentials:MCD, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 LIBERTY HILL RD
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:NC
Mailing Address - Zip Code:28358-2442
Mailing Address - Country:US
Mailing Address - Phone:843-655-2647
Mailing Address - Fax:
Practice Address - Street 1:210 LIBERTY HILL RD
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28358-2442
Practice Address - Country:US
Practice Address - Phone:843-655-2647
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-07
Last Update Date:2014-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSLP.4392 SLP235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist