Provider Demographics
NPI:1528586013
Name:LEE, MARISSA JOY (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:JOY
Last Name:LEE
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 PEARL AVE N
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:GA
Mailing Address - Zip Code:31533-4632
Mailing Address - Country:US
Mailing Address - Phone:912-331-0846
Mailing Address - Fax:678-792-4894
Practice Address - Street 1:4212 CORAL PARK DR
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520
Practice Address - Country:US
Practice Address - Phone:912-996-2069
Practice Address - Fax:912-265-0041
Is Sole Proprietor?:No
Enumeration Date:2017-09-05
Last Update Date:2018-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP10135235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGA00590OtherCERTIFIED BASIC LIFE SUPPORT :CPR AND AED
GASLP10135OtherSPEECH PATHOLOGIST