Healthcare Provider Details

I. General information

NPI: 1003243312
Provider Name (Legal Business Name): MARISSA RAE YOUNG SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2013
Last Update Date: 08/06/2021
Certification Date: 08/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4715 KIRBY LOOP RD
FORT PIERCE FL
34981-5345
US

IV. Provider business mailing address

541 SW FIELDS AVE
PORT ST LUCIE FL
34953-4006
US

V. Phone/Fax

Practice location:
  • Phone: 772-577-6964
  • Fax:
Mailing address:
  • Phone: 561-729-6160
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSI2224
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSZ9191
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSA18025
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: