Provider Demographics
NPI:1902388242
Name:RICKERSON, MARISA
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:
Last Name:RICKERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30800 BERRY CREEK DR
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78628-1121
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:SPJST
Practice Address - Street 2:1810 OLD GRANGER RD
Practice Address - City:TAYLOE
Practice Address - State:TX
Practice Address - Zip Code:76574
Practice Address - Country:US
Practice Address - Phone:512-352-6337
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-04
Last Update Date:2018-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX103418235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist