Provider Demographics
NPI:1659658482
Name:ROBERTS, MARISSA C (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:MARISSA
Middle Name:C
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:189 N UTICA AVE
Mailing Address - Street 2:
Mailing Address - City:N MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758-2143
Mailing Address - Country:US
Mailing Address - Phone:516-586-5498
Mailing Address - Fax:
Practice Address - Street 1:189 N UTICA AVE
Practice Address - Street 2:
Practice Address - City:N MASSAPEQUA
Practice Address - State:NY
Practice Address - Zip Code:11758-2143
Practice Address - Country:US
Practice Address - Phone:516-586-5498
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-08
Last Update Date:2011-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018218-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist