Healthcare Provider Details

I. General information

NPI: 1053723510
Provider Name (Legal Business Name): MARISSA EILEEN PATRICK CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARISSA EILEEN MUNGLE

II. Dates (important events)

Enumeration Date: 06/02/2014
Last Update Date: 06/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1216 HILLCREST DR
SHERMAN TX
75092-5507
US

IV. Provider business mailing address

1107 BAYLOR RD
MELISSA TX
75454-2180
US

V. Phone/Fax

Practice location:
  • Phone: 903-893-7457
  • Fax:
Mailing address:
  • Phone: 205-821-6770
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: