Provider Demographics
NPI:1013623651
Name:LAU, MARISSA (MS, RDN, CDN)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:LAU
Suffix:
Gender:F
Credentials:MS, RDN, CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:967 N BROADWAY
Mailing Address - Street 2:
Mailing Address - City:YONKERS
Mailing Address - State:NY
Mailing Address - Zip Code:10701-1301
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1088 N BROADWAY
Practice Address - Street 2:
Practice Address - City:YONKERS
Practice Address - State:NY
Practice Address - Zip Code:10701-1107
Practice Address - Country:US
Practice Address - Phone:914-964-4408
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-26
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174H00000X
NY011295133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No174H00000XOther Service ProvidersHealth Educator