Healthcare Provider Details

I. General information

NPI: 1174097356
Provider Name (Legal Business Name): MARISSA J OGBOH DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2019
Last Update Date: 01/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21550 HARRINGTON ST STE D
CLINTON TWP MI
48036-2362
US

IV. Provider business mailing address

1773 STAR BATT DR
ROCHESTER HILLS MI
48309-3708
US

V. Phone/Fax

Practice location:
  • Phone: 586-783-7590
  • Fax:
Mailing address:
  • Phone: 248-601-9207
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501019049
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: