MEDICARE: MARISA IRIZARRY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program
2	235Z00000X	Speech-Language Pathologist	SL012549	PA

General Provider Information

NPI Number	:	1679984074
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARISA IRIZARRY

Provider Business Mailing Address
First Line	:	301 LAKE ST
Second Line	:	PO BOX 370
City	:	DALLAS
State	:	PA
Zip	:	18612-7752
Country	:	US
Telephone Number	:	570-675-2131
Fax Number	:

Provider Business Practice Location Address
First Line	:	301 LAKE ST
Second Line	:
City	:	DALLAS
State	:	PA
Zip	:	18612-7752
Country	:	US
Telephone Number	:	570-675-2131
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/19/2014
Last Update Date	:	06/21/2016

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Directions to “ MARISA IRIZARRY ” Practice Location

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