Provider Demographics
NPI:1447458799
Name:MARRA, JEREMY (ATC,CSCS)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:MARRA
Suffix:
Gender:M
Credentials:ATC,CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 AVERYVILLE LN
Mailing Address - Street 2:
Mailing Address - City:LAKE PLACID
Mailing Address - State:NY
Mailing Address - Zip Code:12946-3002
Mailing Address - Country:US
Mailing Address - Phone:734-502-6031
Mailing Address - Fax:
Practice Address - Street 1:60 AVERYVILLE LN
Practice Address - Street 2:
Practice Address - City:LAKE PLACID
Practice Address - State:NY
Practice Address - Zip Code:12946-3002
Practice Address - Country:US
Practice Address - Phone:734-502-6031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-09
Last Update Date:2022-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI26010000822255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer