Provider Demographics
NPI:1467700047
Name:VALLE, MARISSA ANNE (PT)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:ANNE
Last Name:VALLE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:187 MILLBURN AVE 110
Mailing Address - Street 2:
Mailing Address - City:MILLBURN
Mailing Address - State:NJ
Mailing Address - Zip Code:07041-1845
Mailing Address - Country:US
Mailing Address - Phone:973-467-7976
Mailing Address - Fax:
Practice Address - Street 1:922 MAIN STREET
Practice Address - Street 2:
Practice Address - City:PATERSON
Practice Address - State:NJ
Practice Address - Zip Code:07503-3766
Practice Address - Country:US
Practice Address - Phone:973-839-1003
Practice Address - Fax:973-839-3653
Is Sole Proprietor?:No
Enumeration Date:2012-08-29
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01452900225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist