Provider Demographics
NPI:1629694732
Name:MUNOA, MARISSA (MCD, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:MUNOA
Suffix:
Gender:F
Credentials:MCD, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1732 N 1550 E
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-5732
Mailing Address - Country:US
Mailing Address - Phone:760-807-1587
Mailing Address - Fax:
Practice Address - Street 1:1732 N 1550 E
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-5732
Practice Address - Country:US
Practice Address - Phone:760-807-1587
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-24
Last Update Date:2020-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT45982235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist