Provider Demographics
NPI:1306420716
Name:MOORE, MARISSA MARION (MA)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:MARION
Last Name:MOORE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:MARISSA
Other - Middle Name:MARION
Other - Last Name:WILLETTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:156 WINGS MILLS RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:ME
Mailing Address - Zip Code:04352-3811
Mailing Address - Country:US
Mailing Address - Phone:207-604-4547
Mailing Address - Fax:
Practice Address - Street 1:72 STRAWBERRY AVE
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-5952
Practice Address - Country:US
Practice Address - Phone:207-782-2150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-11
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist