Provider Demographics
NPI:1447727268
Name:WISE, MARISSA KATHERINE (LMT)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:KATHERINE
Last Name:WISE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:COHOCTON
Mailing Address - State:NY
Mailing Address - Zip Code:14826-9401
Mailing Address - Country:US
Mailing Address - Phone:585-944-8700
Mailing Address - Fax:
Practice Address - Street 1:28 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:COHOCTON
Practice Address - State:NY
Practice Address - Zip Code:14826-9998
Practice Address - Country:US
Practice Address - Phone:585-704-1624
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-30
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY030654225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist