Provider Demographics
NPI:1720535230
Name:DEXTER, MARISA
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:
Last Name:DEXTER
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 1:24 ROBIN RD
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:WA
Mailing Address - Zip Code:99323-9508
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:24 ROBIN RD
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:WA
Practice Address - Zip Code:99323
Practice Address - Country:US
Practice Address - Phone:509-492-7217
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60663622225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist