Provider Demographics
NPI:1962859553
Name:HANLON, MARISSA M (PT)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:M
Last Name:HANLON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 CANALVIEW MALL
Mailing Address - Street 2:SUITE C
Mailing Address - City:FULTON
Mailing Address - State:NY
Mailing Address - Zip Code:13069-1838
Mailing Address - Country:US
Mailing Address - Phone:315-593-8786
Mailing Address - Fax:315-598-5538
Practice Address - Street 1:10 CANALVIEW MALL
Practice Address - Street 2:SUITE C
Practice Address - City:FULTON
Practice Address - State:NY
Practice Address - Zip Code:13069-1838
Practice Address - Country:US
Practice Address - Phone:315-593-8786
Practice Address - Fax:315-598-5538
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-24
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY026602-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist