Provider Demographics
NPI:1306522834
Name:KLEJBUK, MARISSA (LCAT)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:KLEJBUK
Suffix:
Gender:F
Credentials:LCAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 MAIN ST # 1081
Mailing Address - Street 2:
Mailing Address - City:BREWSTER
Mailing Address - State:NY
Mailing Address - Zip Code:10509-6402
Mailing Address - Country:US
Mailing Address - Phone:845-270-5741
Mailing Address - Fax:
Practice Address - Street 1:12 MAIN ST # 1081
Practice Address - Street 2:
Practice Address - City:BREWSTER
Practice Address - State:NY
Practice Address - Zip Code:10509-6402
Practice Address - Country:US
Practice Address - Phone:845-270-5741
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-27
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002099221700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt TherapistGroup - Single Specialty