Provider Demographics
NPI:1760768691
Name:CHURCHILL, MARISSA N (MOT, OTR/L)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:N
Last Name:CHURCHILL
Suffix:
Gender:F
Credentials:MOT, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19420 84TH AVE W
Mailing Address - Street 2:
Mailing Address - City:EDMONDS
Mailing Address - State:WA
Mailing Address - Zip Code:98026-6102
Mailing Address - Country:US
Mailing Address - Phone:206-465-3214
Mailing Address - Fax:
Practice Address - Street 1:728 2ND ST
Practice Address - Street 2:
Practice Address - City:MUKILTEO
Practice Address - State:WA
Practice Address - Zip Code:98275-1554
Practice Address - Country:US
Practice Address - Phone:425-697-9820
Practice Address - Fax:208-643-7434
Is Sole Proprietor?:No
Enumeration Date:2011-10-24
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOT60140242225X00000X, 225XR0403X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XR0403XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistDriving and Community Mobility
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist