Provider Demographics
NPI:1316276793
Name:KINNEY, MARISA JAYE (MS, CCC-SLP)
Entity type:Individual
Prefix:MS
First Name:MARISA
Middle Name:JAYE
Last Name:KINNEY
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:MISS
Other - First Name:MARISA
Other - Middle Name:JAYE
Other - Last Name:HATHAWAY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4101 W. NASHVILLE ST.
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012
Mailing Address - Country:US
Mailing Address - Phone:918-829-8263
Mailing Address - Fax:501-223-8075
Practice Address - Street 1:4101 W. NASHVILLE ST.
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012
Practice Address - Country:US
Practice Address - Phone:918-829-8263
Practice Address - Fax:501-223-8075
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-15
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARSP#1907235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist