Provider Demographics
NPI:1457829772
Name:MCRAE, MARISSA (SLP)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:MCRAE
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21605 SUPERIOR RD
Mailing Address - Street 2:
Mailing Address - City:TAYLOR
Mailing Address - State:MI
Mailing Address - Zip Code:48180-4752
Mailing Address - Country:US
Mailing Address - Phone:313-999-9943
Mailing Address - Fax:
Practice Address - Street 1:1660 FORT ST
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:MI
Practice Address - Zip Code:48183-2003
Practice Address - Country:US
Practice Address - Phone:734-304-4159
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-05
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101004909235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist