Provider Demographics
NPI:1851826200
Name:GREENBERG, MARISSA TRACY (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:TRACY
Last Name:GREENBERG
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:MARISSA
Other - Middle Name:TRACY
Other - Last Name:LEDERMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1070 E 104TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11236-4526
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1070 E 104TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11236-4526
Practice Address - Country:US
Practice Address - Phone:718-444-4316
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-24
Last Update Date:2019-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
235Z00000X
NY14317721235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist