Provider Demographics
NPI:1053109686
Name:RENELLA, MARISSA (MT-BC, MTL)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:RENELLA
Suffix:
Gender:
Credentials:MT-BC, MTL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2506 WETMORE AVE APT A
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-2920
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4033 E MADISON ST STE 108
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98112-3104
Practice Address - Country:US
Practice Address - Phone:206-438-4068
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-25
Last Update Date:2025-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMU61651326225A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
14090OtherCERTIFICATION BOARD FOR MUSIC THERAPISTS
WAMU61651326OtherWASHINGTON STATE DEPARTMENT OF HEALTH