Provider Demographics
NPI:1790280964
Name:SLAUGHTER, MARISSA DANIELLE (COTA)
Entity Type:Individual
Prefix:MISS
First Name:MARISSA
Middle Name:DANIELLE
Last Name:SLAUGHTER
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9525 STEVENS RD
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106-7530
Mailing Address - Country:US
Mailing Address - Phone:318-729-3911
Mailing Address - Fax:
Practice Address - Street 1:4405 AIRLINE DR
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-2058
Practice Address - Country:US
Practice Address - Phone:318-747-5440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-28
Last Update Date:2018-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA308139224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant