Provider Demographics
NPI:1306298443
Name:SLATE, MARISSA (PT, DPT)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:SLATE
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9565 HWY 78 BLDG 700 STE 102
Mailing Address - Street 2:
Mailing Address - City:LADSON
Mailing Address - State:SC
Mailing Address - Zip Code:29456-4116
Mailing Address - Country:US
Mailing Address - Phone:843-314-5434
Mailing Address - Fax:888-510-9156
Practice Address - Street 1:9565 HIGHWAY 78 STE 102
Practice Address - Street 2:
Practice Address - City:LADSON
Practice Address - State:SC
Practice Address - Zip Code:29456-4118
Practice Address - Country:US
Practice Address - Phone:843-314-5434
Practice Address - Fax:888-510-9156
Is Sole Proprietor?:No
Enumeration Date:2016-07-12
Last Update Date:2017-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT315442251P0200X
SCPT 81912251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics