Provider Demographics
NPI:1922386044
Name:ULM, MARISSA L (SLP)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:L
Last Name:ULM
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2338 W SUD PKWY
Mailing Address - Street 2:SUITE 3100
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-7482
Mailing Address - Country:US
Mailing Address - Phone:309-693-9189
Mailing Address - Fax:309-693-9946
Practice Address - Street 1:2338 W SUD PKWY
Practice Address - Street 2:SUITE 3100
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-7482
Practice Address - Country:US
Practice Address - Phone:309-693-9189
Practice Address - Fax:309-693-9946
Is Sole Proprietor?:No
Enumeration Date:2011-07-22
Last Update Date:2011-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL242001914235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist