=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902305535
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARISSA LETTINGTON
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/09/2018
-----------------------------------------------------
Last Update Date | 11/14/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1470 INDUSTRIAL DR NW
-----------------------------------------------------
City | ROCHESTER
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55901-0700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 507-322-7750
-----------------------------------------------------
Fax | 920-857-3366
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1470 INDUSTRIAL DR NW
-----------------------------------------------------
City | ROCHESTER
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55901-0700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 507-332-7750
-----------------------------------------------------
Fax | 920-857-3366
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number | 1-22-62307
-----------------------------------------------------
License Number State | SD
-----------------------------------------------------