Provider Demographics
NPI:1508337940
Name:DE LOS SANTOS, MARISSA
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:DE LOS SANTOS
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 1:251 JOHNSTON ST SE STE 200
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:AL
Mailing Address - Zip Code:35601-2515
Mailing Address - Country:US
Mailing Address - Phone:256-350-1764
Mailing Address - Fax:
Practice Address - Street 1:2541 PASS RD STE F
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39531-2112
Practice Address - Country:US
Practice Address - Phone:228-388-1002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-11
Last Update Date:2018-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT6160225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist