Healthcare Provider Details

I. General information

NPI: 1457796260
Provider Name (Legal Business Name): MARISSA MOSCHANTHI KOLCUM M.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/07/2013
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5625 WINDSOR WAY
CULVER CITY CA
90230-6762
US

IV. Provider business mailing address

7841 MELOTTE ST
SAN DIEGO CA
92119-1237
US

V. Phone/Fax

Practice location:
  • Phone: 310-384-5317
  • Fax:
Mailing address:
  • Phone: 619-672-6817
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number20768
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: