Provider Demographics
NPI:1376909044
Name:CARLYON, MARISSA
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:CARLYON
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 1:2812 W 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:EMPORIA
Mailing Address - State:KS
Mailing Address - Zip Code:66801-6202
Mailing Address - Country:US
Mailing Address - Phone:620-208-7878
Mailing Address - Fax:620-208-7000
Practice Address - Street 1:1102 SAINT MARYS RD
Practice Address - Street 2:
Practice Address - City:JUNCTION CITY
Practice Address - State:KS
Practice Address - Zip Code:66441
Practice Address - Country:US
Practice Address - Phone:785-762-3350
Practice Address - Fax:785-762-3920
Is Sole Proprietor?:No
Enumeration Date:2016-01-11
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-05089225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist