Healthcare Provider Details

I. General information

NPI: 1992127229
Provider Name (Legal Business Name): MARISSA REIS PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/06/2014
Last Update Date: 01/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1211 SW 132ND LN APT 412
BURIEN WA
98146-4009
US

IV. Provider business mailing address

1211 SW 132ND LN APT 412
BURIEN WA
98146-4009
US

V. Phone/Fax

Practice location:
  • Phone: 206-331-7816
  • Fax:
Mailing address:
  • Phone: 206-331-7816
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberPT00009162
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License NumberPT00009162
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: