Provider Demographics
NPI:1831690452
Name:TRUJILLO, MARISSA
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:TRUJILLO
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 1:6501 SAN ANTONIO DR NE UNIT 4202
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-4146
Mailing Address - Country:US
Mailing Address - Phone:505-804-8488
Mailing Address - Fax:
Practice Address - Street 1:6501 SAN ANTONIO DR NE UNIT 4202
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-4146
Practice Address - Country:US
Practice Address - Phone:505-804-8488
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-28
Last Update Date:2025-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NMSLP22039235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program