Healthcare Provider Details

I. General information

NPI: 1376125773
Provider Name (Legal Business Name): MARISA AHTONEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2021
Last Update Date: 07/31/2026
Certification Date: 07/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1370 BROWNING RD STE 100
COLUMBIA SC
29210-6939
US

IV. Provider business mailing address

350 FAIRWAY DR STE 101
DEERFIELD BEACH FL
33441-1834
US

V. Phone/Fax

Practice location:
  • Phone: 839-213-4505
  • Fax:
Mailing address:
  • Phone: 615-247-5487
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-24-73250
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: