Provider Demographics
NPI:1891207080
Name:BERGSMA, MARISSA LAUREN (MS CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:MARISSA
Middle Name:LAUREN
Last Name:BERGSMA
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:MISS
Other - First Name:MARISSA
Other - Middle Name:LAUREN
Other - Last Name:ORR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2915 EARLE AVE SW
Mailing Address - Street 2:
Mailing Address - City:GRANDVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49418-1467
Mailing Address - Country:US
Mailing Address - Phone:616-260-3174
Mailing Address - Fax:
Practice Address - Street 1:2786 56TH ST SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49418-8708
Practice Address - Country:US
Practice Address - Phone:616-261-3960
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-29
Last Update Date:2017-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101004623235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist