Provider Demographics
NPI:1679984074
Name:IRIZARRY, MARISA
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:
Last Name:IRIZARRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 LAKE ST
Mailing Address - Street 2:PO BOX 370
Mailing Address - City:DALLAS
Mailing Address - State:PA
Mailing Address - Zip Code:18612-7752
Mailing Address - Country:US
Mailing Address - Phone:570-675-2131
Mailing Address - Fax:
Practice Address - Street 1:301 LAKE ST
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:PA
Practice Address - Zip Code:18612-7752
Practice Address - Country:US
Practice Address - Phone:570-675-2131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-19
Last Update Date:2016-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PASL012549235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program