Healthcare Provider Details

I. General information

NPI: 1821689902
Provider Name (Legal Business Name): MARISSA SWALBY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2021
Last Update Date: 02/01/2021
Certification Date: 02/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3530 PAN AMERICAN FWY NE STE D
ALBUQUERQUE NM
87107-4793
US

IV. Provider business mailing address

104 FIVE HILLS DR
TIJERAS NM
87059-7484
US

V. Phone/Fax

Practice location:
  • Phone: 505-888-4569
  • Fax:
Mailing address:
  • Phone: 505-615-9131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number2103
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: