Provider Demographics
NPI:1124641634
Name:HORTON, MARISSA
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:HORTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 W UTICA PL
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74011-2447
Mailing Address - Country:US
Mailing Address - Phone:918-231-8618
Mailing Address - Fax:
Practice Address - Street 1:4908 S SHERIDAN RD
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74145-5712
Practice Address - Country:US
Practice Address - Phone:918-984-9153
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-19
Last Update Date:2022-07-11
Deactivation Date:2021-08-31
Deactivation Code:
Reactivation Date:2021-10-20
Provider Licenses
StateLicense IDTaxonomies
OK2343224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant