Provider Demographics
NPI:1184962706
Name:GARVICH, MARISSA BRIANNA (MA CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:MARISSA
Middle Name:BRIANNA
Last Name:GARVICH
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:MISS
Other - First Name:MARISSA
Other - Middle Name:BRIANNA
Other - Last Name:COFFERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1309 OAK AVE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:WACONIA
Mailing Address - State:MN
Mailing Address - Zip Code:55387-1078
Mailing Address - Country:US
Mailing Address - Phone:952-223-2506
Mailing Address - Fax:952-443-2038
Practice Address - Street 1:1309 OAK AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:WACONIA
Practice Address - State:MN
Practice Address - Zip Code:55387-1078
Practice Address - Country:US
Practice Address - Phone:952-223-2506
Practice Address - Fax:952-443-2038
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-17
Last Update Date:2014-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSZ6115235Z00000X
MN9394235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist