Provider Demographics
NPI:1558833996
Name:TOELLE, MARISSA
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:TOELLE
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 1:217 E PARK ST
Mailing Address - Street 2:
Mailing Address - City:NEW LISBON
Mailing Address - State:WI
Mailing Address - Zip Code:53950-1353
Mailing Address - Country:US
Mailing Address - Phone:608-547-5516
Mailing Address - Fax:
Practice Address - Street 1:1505 BUTTS AVE
Practice Address - Street 2:
Practice Address - City:TOMAH
Practice Address - State:WI
Practice Address - Zip Code:54660-2405
Practice Address - Country:US
Practice Address - Phone:608-372-3241
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-26
Last Update Date:2018-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5517-27224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant