Provider Demographics
NPI:1811362049
Name:HECKSTALL, MARISA ELISABET (SLPA)
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:ELISABET
Last Name:HECKSTALL
Suffix:
Gender:F
Credentials:SLPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 CORAL WAY
Mailing Address - Street 2:SUITE 207
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33145-2934
Mailing Address - Country:US
Mailing Address - Phone:305-854-7244
Mailing Address - Fax:786-375-5544
Practice Address - Street 1:1300 CORAL WAY
Practice Address - Street 2:SUITE 207
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33145-2934
Practice Address - Country:US
Practice Address - Phone:305-854-7244
Practice Address - Fax:786-375-5544
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-14
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSI10372355S0801X
FLSZ11439235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL119299500Medicaid