Provider Demographics
NPI:1467980193
Name:DIRIENZO, MARISA ROSE
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:ROSE
Last Name:DIRIENZO
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 1:168 STRATFORD S
Mailing Address - Street 2:
Mailing Address - City:ROSLYN HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11577-2318
Mailing Address - Country:US
Mailing Address - Phone:516-592-3080
Mailing Address - Fax:
Practice Address - Street 1:1983 MARCUS AVE STE C118
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11042-1016
Practice Address - Country:US
Practice Address - Phone:516-497-7600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-25
Last Update Date:2017-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021384225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics