Provider Demographics
NPI:1942688064
Name:MCCOLLISTER, MARISSA
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:MCCOLLISTER
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 1:3791 LEE MOORE RD
Mailing Address - Street 2:
Mailing Address - City:MAIDEN
Mailing Address - State:NC
Mailing Address - Zip Code:28650-9226
Mailing Address - Country:US
Mailing Address - Phone:740-506-2877
Mailing Address - Fax:
Practice Address - Street 1:2201 S STERLING ST
Practice Address - Street 2:
Practice Address - City:MORGANTON
Practice Address - State:NC
Practice Address - Zip Code:28655-4044
Practice Address - Country:US
Practice Address - Phone:828-580-6826
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-08
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2255A2300X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer