Provider Demographics
NPI:1831522903
Name:DALCOLLO, MARISSA ANNE (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:ANNE
Last Name:DALCOLLO
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:98 ROXBURY DR
Mailing Address - Street 2:
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725-1336
Mailing Address - Country:US
Mailing Address - Phone:631-327-4685
Mailing Address - Fax:
Practice Address - Street 1:98 ROXBURY DR
Practice Address - Street 2:
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725-1336
Practice Address - Country:US
Practice Address - Phone:631-327-4685
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-13
Last Update Date:2020-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY023822-01235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program