Provider Demographics
NPI:1699947473
Name:SCOTT, MARISSA D (CCC-SLP)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:D
Last Name:SCOTT
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9732 PORCUPINE PATH
Mailing Address - Street 2:
Mailing Address - City:TOMAHAWK
Mailing Address - State:WI
Mailing Address - Zip Code:54487-9366
Mailing Address - Country:US
Mailing Address - Phone:715-966-1960
Mailing Address - Fax:715-453-7384
Practice Address - Street 1:9732 PORCUPINE PATH
Practice Address - Street 2:
Practice Address - City:TOMAHAWK
Practice Address - State:WI
Practice Address - Zip Code:54487-9366
Practice Address - Country:US
Practice Address - Phone:715-966-1960
Practice Address - Fax:715-453-7384
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-01
Last Update Date:2012-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2957235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42588100Medicaid