Provider Demographics
NPI:1982162004
Name:BURCH, MARISSA RAE
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:RAE
Last Name:BURCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:59 LIDDIE LOU
Mailing Address - Street 2:
Mailing Address - City:WINFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63389-3138
Mailing Address - Country:US
Mailing Address - Phone:636-358-6479
Mailing Address - Fax:
Practice Address - Street 1:59 LIDDIE LOU
Practice Address - Street 2:
Practice Address - City:WINFIELD
Practice Address - State:MO
Practice Address - Zip Code:63389-3138
Practice Address - Country:US
Practice Address - Phone:636-358-6479
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-07
Last Update Date:2019-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer