Provider Demographics
NPI:1619485273
Name:HAUG, MARISSA LYNN (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:LYNN
Last Name:HAUG
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2803 S WHEATFIELD DR
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54915-2168
Mailing Address - Country:US
Mailing Address - Phone:920-629-9831
Mailing Address - Fax:
Practice Address - Street 1:N4021 COUNTY RD E
Practice Address - Street 2:
Practice Address - City:FREEDOM
Practice Address - State:WI
Practice Address - Zip Code:54130-7593
Practice Address - Country:US
Practice Address - Phone:920-788-7940
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-17
Last Update Date:2018-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI20000110622255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer