Provider Demographics
NPI:1609528124
Name:ISLAS, MARISSA (COTA/L)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:ISLAS
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3228 DUKE AVE
Mailing Address - Street 2:
Mailing Address - City:BIG SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:79720-3517
Mailing Address - Country:US
Mailing Address - Phone:432-935-3748
Mailing Address - Fax:
Practice Address - Street 1:1901 N US HIGHWAY 87
Practice Address - Street 2:
Practice Address - City:BIG SPRING
Practice Address - State:TX
Practice Address - Zip Code:79720-0283
Practice Address - Country:US
Practice Address - Phone:432-267-8216
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-25
Last Update Date:2023-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX217067224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant