Provider Demographics
NPI:1942750997
Name:PERRY, MARISSA (COTA/L)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:PERRY
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:74 3RD ST
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:MS
Mailing Address - Zip Code:38732-9745
Mailing Address - Country:US
Mailing Address - Phone:662-721-0272
Mailing Address - Fax:
Practice Address - Street 1:74 3RD ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:MS
Practice Address - Zip Code:38732-9745
Practice Address - Country:US
Practice Address - Phone:662-721-0272
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-13
Last Update Date:2016-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSTA3155224Z00000X
MDA02401224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant