Provider Demographics
NPI:1407108830
Name:BORUCHOW, MARISSA IVY (MS, CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:MARISSA
Middle Name:IVY
Last Name:BORUCHOW
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 E 50TH ST APT 10E
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10022-7941
Mailing Address - Country:US
Mailing Address - Phone:516-376-1041
Mailing Address - Fax:
Practice Address - Street 1:311 E 50TH ST APT 10E
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10022-7941
Practice Address - Country:US
Practice Address - Phone:516-376-1041
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-09
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022171235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist