Provider Demographics
NPI:1629512116
Name:BROMAN, MARISSA ANNE (CCC SLP)
Entity Type:Individual
Prefix:MS
First Name:MARISSA
Middle Name:ANNE
Last Name:BROMAN
Suffix:
Gender:F
Credentials:CCC SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:361 CARROLL ST
Mailing Address - Street 2:APT 1E
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11231-5064
Mailing Address - Country:US
Mailing Address - Phone:908-812-0536
Mailing Address - Fax:
Practice Address - Street 1:4004 4TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11232-3402
Practice Address - Country:US
Practice Address - Phone:718-840-1962
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-19
Last Update Date:2016-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022884235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist