Provider Demographics
NPI:1801405022
Name:HUMPHREY, MARISSA LYNN (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:LYNN
Last Name:HUMPHREY
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9216 HAWTHORN DR
Mailing Address - Street 2:
Mailing Address - City:DAVISON
Mailing Address - State:MI
Mailing Address - Zip Code:48423-2084
Mailing Address - Country:US
Mailing Address - Phone:810-701-9271
Mailing Address - Fax:
Practice Address - Street 1:320 N MAIN ST
Practice Address - Street 2:
Practice Address - City:DAVISON
Practice Address - State:MI
Practice Address - Zip Code:48423-1423
Practice Address - Country:US
Practice Address - Phone:810-412-4573
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-23
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101006194235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist