Provider Demographics
NPI:1316492358
Name:MCBRIDE, MARISSA (DPT)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:MCBRIDE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:MARISSA
Other - Middle Name:ROSE
Other - Last Name:DEANGELIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:101 BURRS RD STE G
Mailing Address - Street 2:
Mailing Address - City:WESTAMPTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08060-5518
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:101 BURRS RD STE G
Practice Address - Street 2:
Practice Address - City:WESTAMPTON
Practice Address - State:NJ
Practice Address - Zip Code:08060-5518
Practice Address - Country:US
Practice Address - Phone:608-261-4330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-19
Last Update Date:2016-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01453500172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker