Healthcare Provider Details

I. General information

NPI: 1003081993
Provider Name (Legal Business Name): MARZELLE CLAASSEN BLACK PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2008
Last Update Date: 03/27/2020
Certification Date: 03/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16420 W US HIGHWAY 24
WOODLAND PARK CO
80863-8760
US

IV. Provider business mailing address

711 AVIGNON DR
RIDGELAND MS
39157-5120
US

V. Phone/Fax

Practice location:
  • Phone: 719-374-6172
  • Fax: 719-374-6118
Mailing address:
  • Phone: 601-605-6777
  • Fax: 601-605-8869

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT1649
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: