Basic Information
| Provider Information | |||||||||
| NPI: | 1760768691 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHURCHILL | ||||||||
| FirstName: | MARISSA | ||||||||
| MiddleName: | N | ||||||||
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| Credential: | MOT, OTR/L, PBP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 916 CLEVELAND AVE | ||||||||
| Address2: | |||||||||
| City: | SNOHOMISH | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98290 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2064653214 | ||||||||
| FaxNumber: | 5036504302 | ||||||||
| Practice Location | |||||||||
| Address1: | 817 238TH ST. SE | ||||||||
| Address2: | SUITE H | ||||||||
| City: | BOTHELL | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2064653214 | ||||||||
| FaxNumber: | 5036504302 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2011 | ||||||||
| LastUpdateDate: | 06/14/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 268812 | OR | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225XR0403X | OT60140242 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Driving and Community Mobility |
No ID Information.