Healthcare Provider Details

I. General information

NPI: 1063322956
Provider Name (Legal Business Name): MARISSA RUTH RBT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2026
Last Update Date: 09/11/2026
Certification Date: 09/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

617 FRANKLIN AVE UNIT 12
BERLIN MD
21811-1358
US

IV. Provider business mailing address

17051 REDDEN RD
GEORGETOWN DE
19947-3339
US

V. Phone/Fax

Practice location:
  • Phone: 302-212-7091
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-26-2843218
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: