Provider Demographics
NPI:1316472574
Name:IMHOF, MARISA ANNE
Entity type:Individual
Prefix:
First Name:MARISA
Middle Name:ANNE
Last Name:IMHOF
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 WESTCHESTER AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:PURCHASE
Mailing Address - State:NY
Mailing Address - Zip Code:10577-2547
Mailing Address - Country:US
Mailing Address - Phone:914-564-6879
Mailing Address - Fax:
Practice Address - Street 1:2700 WESTCHESTER AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:PURCHASE
Practice Address - State:NY
Practice Address - Zip Code:10577-2547
Practice Address - Country:US
Practice Address - Phone:914-564-6879
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-25
Last Update Date:2018-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1082587161174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist