Provider Demographics
NPI:1205661246
Name:MASTEN, MARISSA ANN (MTRS, TRS, MS)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:ANN
Last Name:MASTEN
Suffix:
Gender:F
Credentials:MTRS, TRS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4179 S RIVERBOAT RD STE 240
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84123-2986
Mailing Address - Country:US
Mailing Address - Phone:385-399-0828
Mailing Address - Fax:
Practice Address - Street 1:4179 S RIVERBOAT RD STE 240
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84123-2986
Practice Address - Country:US
Practice Address - Phone:385-399-0828
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-06
Last Update Date:2024-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6820377225800000X
225800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist