Provider Demographics
NPI:1790162360
Name:BROOKS, MARISSA NICHOLE
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:NICHOLE
Last Name:BROOKS
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 1:931 DOUGLASS AVE
Mailing Address - Street 2:
Mailing Address - City:ELKINS PARK
Mailing Address - State:PA
Mailing Address - Zip Code:19027-1626
Mailing Address - Country:US
Mailing Address - Phone:732-754-8325
Mailing Address - Fax:
Practice Address - Street 1:3600 ARAMINGO AVE # 11
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19134-4608
Practice Address - Country:US
Practice Address - Phone:215-203-1930
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-02
Last Update Date:2018-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT023364225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist