Provider Demographics
NPI:1023782463
Name:CHICHESTER, MARISSA (DPT)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:CHICHESTER
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1650 LYNDON FARM CT STE 300
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-5005
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:224 N RIVERSIDE AVE STE A
Practice Address - Street 2:
Practice Address - City:RIALTO
Practice Address - State:CA
Practice Address - Zip Code:92376-5968
Practice Address - Country:US
Practice Address - Phone:909-873-8369
Practice Address - Fax:909-873-4975
Is Sole Proprietor?:No
Enumeration Date:2021-08-08
Last Update Date:2022-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist