Provider Demographics
NPI:1659783868
Name:VANE, MARISSA (ATC, LAT)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:VANE
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 ENDICOTT ST
Mailing Address - Street 2:#3
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02113-1668
Mailing Address - Country:US
Mailing Address - Phone:408-398-5578
Mailing Address - Fax:
Practice Address - Street 1:1419 COMMONWEALTH AVE
Practice Address - Street 2:APARTMENT 504
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02135-6253
Practice Address - Country:US
Practice Address - Phone:408-398-5578
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-21
Last Update Date:2014-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA24462255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer