Provider Demographics
NPI:1740704626
Name:GRATZA, MARISSA LOUISE (CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:MARISSA
Middle Name:LOUISE
Last Name:GRATZA
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3601 KERNAN BLVD S APT 2022
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224-9692
Mailing Address - Country:US
Mailing Address - Phone:636-357-9966
Mailing Address - Fax:
Practice Address - Street 1:2730 ISABELLA BLVD STE 10
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-8002
Practice Address - Country:US
Practice Address - Phone:904-372-4070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-01
Last Update Date:2018-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSZ8066235Z00000X
FLSA16227235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist