Healthcare Provider Details

I. General information

NPI: 1952918021
Provider Name (Legal Business Name): MARISA BRESLIN AUD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2020
Last Update Date: 09/30/2021
Certification Date: 09/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1925 MOUNTAIN VIEW AVE
LONGMONT CO
80501-3128
US

IV. Provider business mailing address

1925 MOUNTAIN VIEW AVE
LONGMONT CO
80501-3128
US

V. Phone/Fax

Practice location:
  • Phone: 720-494-3120
  • Fax: 720-494-3113
Mailing address:
  • Phone: 720-494-3120
  • Fax: 720-494-3113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License Number319
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License NumberAUD.0000319
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: