Healthcare Provider Details

I. General information

NPI: 1053109686
Provider Name (Legal Business Name): MARISSA RENELLA MT-BC, MTL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2025
Last Update Date: 04/25/2025
Certification Date: 04/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4033 E MADISON ST STE 108
SEATTLE WA
98112-3104
US

IV. Provider business mailing address

2506 WETMORE AVE APT A
EVERETT WA
98201-2920
US

V. Phone/Fax

Practice location:
  • Phone: 206-438-4068
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225A00000X
TaxonomyMusic Therapist
License NumberMU61651326
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: