Basic Information
| Provider Information | |||||||||
| NPI: | 1972183978 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROWN | ||||||||
| FirstName: | MARISSA | ||||||||
| MiddleName: | |||||||||
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| Credential: | RBT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3500 DEPAUW BLVD STE 3070 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462686135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8553240885 | ||||||||
| FaxNumber: | 3175208200 | ||||||||
| Practice Location | |||||||||
| Address1: | 29077 CLEMENS RD | ||||||||
| Address2: | |||||||||
| City: | WESTLAKE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441451135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4408716568 | ||||||||
| FaxNumber: | 3175208200 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2021 | ||||||||
| LastUpdateDate: | 04/13/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | RBT-20-135737 | OH | Y |
No ID Information.