Provider Demographics
NPI:1801195664
Name:DE MARCO, MARISA (MA, SLP-CCC)
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:
Last Name:DE MARCO
Suffix:
Gender:F
Credentials:MA, SLP-CCC
Other - Prefix:
Other - First Name:MARISA
Other - Middle Name:
Other - Last Name:BIANCO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA, SLP-CCC
Mailing Address - Street 1:297 PORT AVE
Mailing Address - Street 2:
Mailing Address - City:RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-4825
Mailing Address - Country:US
Mailing Address - Phone:631-738-0027
Mailing Address - Fax:
Practice Address - Street 1:297 PORT AVE
Practice Address - Street 2:
Practice Address - City:RONKONKOMA
Practice Address - State:NY
Practice Address - Zip Code:11779-4825
Practice Address - Country:US
Practice Address - Phone:631-738-0027
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-19
Last Update Date:2011-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0128741235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist