Provider Demographics
NPI:1447944723
Name:LEIS, MARISSA (MS)
Entity type:Individual
Prefix:MRS
First Name:MARISSA
Middle Name:
Last Name:LEIS
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:88 BARRETT AVE
Mailing Address - Street 2:
Mailing Address - City:BAYPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11705-1410
Mailing Address - Country:US
Mailing Address - Phone:631-455-9820
Mailing Address - Fax:
Practice Address - Street 1:88 BARRETT AVE
Practice Address - Street 2:
Practice Address - City:BAYPORT
Practice Address - State:NY
Practice Address - Zip Code:11705-1410
Practice Address - Country:US
Practice Address - Phone:631-455-9820
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-08
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency