Provider Demographics
NPI:1568934354
Name:SPISSO, HEATHER (MED, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:SPISSO
Suffix:
Gender:F
Credentials:MED, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12638 JESSE SMITH RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT AIRY
Mailing Address - State:MD
Mailing Address - Zip Code:21771-5938
Mailing Address - Country:US
Mailing Address - Phone:301-865-4452
Mailing Address - Fax:
Practice Address - Street 1:9051 RIDGEFIELD DR
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21701-6740
Practice Address - Country:US
Practice Address - Phone:240-236-1600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-18
Last Update Date:2018-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD03567235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty