Provider Demographics
NPI:1013464585
Name:MUNDY, MARISSA ANN (OTR/L)
Entity Type:Individual
Prefix:MS
First Name:MARISSA
Middle Name:ANN
Last Name:MUNDY
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 WEST 15TH ROAD
Mailing Address - Street 2:
Mailing Address - City:BROAD CHANNEL
Mailing Address - State:NY
Mailing Address - Zip Code:11693
Mailing Address - Country:US
Mailing Address - Phone:917-972-8157
Mailing Address - Fax:
Practice Address - Street 1:55 WEST 15TH ROAD
Practice Address - Street 2:
Practice Address - City:BROAD CHANNEL
Practice Address - State:NY
Practice Address - Zip Code:11693
Practice Address - Country:US
Practice Address - Phone:917-972-8157
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020869225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist