1033436134 NPI number — MARISA LYNN CROOKS M.A., CCC-SLP

Table of content: MARISA LYNN CROOKS M.A., CCC-SLP (NPI 1033436134)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033436134 NPI number — MARISA LYNN CROOKS M.A., CCC-SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CROOKS
Provider First Name:
MARISA
Provider Middle Name:
LYNN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.A., CCC-SLP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1033436134
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/18/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2998
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WINTER PARK
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32790-2998
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-435-5652
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2125 PORTLIGHT DR
Provider Second Line Business Practice Location Address:
201
Provider Business Practice Location Address City Name:
ORLANDO
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32814-6951
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-435-5652
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/28/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  SA10273 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 222Q00000X , with the licence number: SA 10273 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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