Provider Demographics
NPI:1396872297
Name:MUCCIO, MARISSA M (PT)
Entity type:Individual
Prefix:MR
First Name:MARISSA
Middle Name:M
Last Name:MUCCIO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 BLACK OAK RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07470-6504
Mailing Address - Country:US
Mailing Address - Phone:973-692-9072
Mailing Address - Fax:973-692-9071
Practice Address - Street 1:309 BLACK OAK RIDGE RD
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:NJ
Practice Address - Zip Code:07470-6504
Practice Address - Country:US
Practice Address - Phone:973-692-9072
Practice Address - Fax:973-692-9071
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJPT40QA00794200174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist