Provider Demographics
NPI:1316784937
Name:VALDIVIA, MARISSA LEIGH (SLP)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:LEIGH
Last Name:VALDIVIA
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4001 ROSS AVE APT 148
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75204-5256
Mailing Address - Country:US
Mailing Address - Phone:806-678-9531
Mailing Address - Fax:
Practice Address - Street 1:8505 MID CITIES BLVD
Practice Address - Street 2:
Practice Address - City:NORTH RICHLAND HILLS
Practice Address - State:TX
Practice Address - Zip Code:76182-4718
Practice Address - Country:US
Practice Address - Phone:817-769-2457
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-10
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX122281235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist