Provider Demographics
NPI:1043889694
Name:RIVERA, MARISSA KATHLEEN
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:KATHLEEN
Last Name:RIVERA
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 1:10301 RANCH ROAD 2222 APT 2534
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78730-1280
Mailing Address - Country:US
Mailing Address - Phone:845-699-9198
Mailing Address - Fax:
Practice Address - Street 1:12710 RESEARCH BLVD STE 395
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-4397
Practice Address - Country:US
Practice Address - Phone:512-250-8706
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-18
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX121850225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist