Provider Demographics
NPI:1639988843
Name:ARCHER, MARISSA GRACE (PT, DPT)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:GRACE
Last Name:ARCHER
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4441 N LODGEPOLE CT
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86314-7690
Mailing Address - Country:US
Mailing Address - Phone:928-308-0492
Mailing Address - Fax:
Practice Address - Street 1:1781 AZ-69
Practice Address - Street 2:#27
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301
Practice Address - Country:US
Practice Address - Phone:928-515-3118
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-02
Last Update Date:2025-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPT-033971225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist