Provider Demographics
NPI:1477032605
Name:PRECOUR, MARISSA NICOLE (OTR/L)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:NICOLE
Last Name:PRECOUR
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10264 SCOTT RD
Mailing Address - Street 2:
Mailing Address - City:FREELAND
Mailing Address - State:MI
Mailing Address - Zip Code:48623-8606
Mailing Address - Country:US
Mailing Address - Phone:989-525-3424
Mailing Address - Fax:
Practice Address - Street 1:337 LEMKE ST
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48642-5926
Practice Address - Country:US
Practice Address - Phone:989-492-7766
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-08
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201009744225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1902841414Medicaid