Provider Demographics
NPI:1154404374
Name:CHIANG, MARISSA J (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:J
Last Name:CHIANG
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:MARISSA
Other - Middle Name:J
Other - Last Name:DOUGLAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2927 S FISH HATCHERY RD
Mailing Address - Street 2:
Mailing Address - City:FITCHBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53711-6498
Mailing Address - Country:US
Mailing Address - Phone:608-819-6394
Mailing Address - Fax:
Practice Address - Street 1:2927 S FISH HATCHERY RD
Practice Address - Street 2:
Practice Address - City:FITCHBURG
Practice Address - State:WI
Practice Address - Zip Code:53711-6498
Practice Address - Country:US
Practice Address - Phone:608-819-6394
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2020-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2859-154235Z00000X
MN8287235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42580000Medicaid