Healthcare Provider Details

I. General information

NPI: 1518623602
Provider Name (Legal Business Name): MARISSA PEAK MT-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/12/2021
Last Update Date: 11/12/2021
Certification Date: 11/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11650 DOWNES ST NE
LOWELL MI
49331-9489
US

IV. Provider business mailing address

11650 DOWNES ST NE
LOWELL MI
49331-9489
US

V. Phone/Fax

Practice location:
  • Phone: 616-897-7842
  • Fax: 616-897-7054
Mailing address:
  • Phone: 616-897-7842
  • Fax: 616-897-7054

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225A00000X
TaxonomyMusic Therapist
License Number14940
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: