Provider Demographics
NPI:1578219689
Name:PETSCH, MARISSA MAE
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:MAE
Last Name:PETSCH
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 1:621 N FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:RED CLOUD
Mailing Address - State:NE
Mailing Address - Zip Code:68970-2260
Mailing Address - Country:US
Mailing Address - Phone:402-746-5600
Mailing Address - Fax:402-746-5687
Practice Address - Street 1:621 N FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:RED CLOUD
Practice Address - State:NE
Practice Address - Zip Code:68970-2260
Practice Address - Country:US
Practice Address - Phone:402-746-5600
Practice Address - Fax:402-746-5687
Is Sole Proprietor?:No
Enumeration Date:2022-02-28
Last Update Date:2022-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE3848225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist