Provider Demographics
NPI:1942589825
Name:SHEPHERD, MARISSA LYNN (PTA)
Entity Type:Individual
Prefix:MISS
First Name:MARISSA
Middle Name:LYNN
Last Name:SHEPHERD
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1830 TURTLE HILL RD
Mailing Address - Street 2:
Mailing Address - City:ENTERPRISE
Mailing Address - State:FL
Mailing Address - Zip Code:32725-2452
Mailing Address - Country:US
Mailing Address - Phone:407-314-3106
Mailing Address - Fax:
Practice Address - Street 1:1337 S INTERNATIONAL PKWY
Practice Address - Street 2:
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-1402
Practice Address - Country:US
Practice Address - Phone:407-833-0802
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-10
Last Update Date:2011-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL22209225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant