Provider Demographics
NPI:1376109066
Name:MAGRO, MARISSA MARIE (MS ED, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:MARIE
Last Name:MAGRO
Suffix:
Gender:F
Credentials:MS ED, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 N 21ST ST
Mailing Address - Street 2:
Mailing Address - City:OLEAN
Mailing Address - State:NY
Mailing Address - Zip Code:14760-1906
Mailing Address - Country:US
Mailing Address - Phone:716-307-3249
Mailing Address - Fax:
Practice Address - Street 1:133 N 21ST ST
Practice Address - Street 2:
Practice Address - City:OLEAN
Practice Address - State:NY
Practice Address - Zip Code:14760-1906
Practice Address - Country:US
Practice Address - Phone:716-379-3202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-17
Last Update Date:2022-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202009540235Z00000X
NY031721235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist