Provider Demographics
NPI:1942016506
Name:MODELL, MARRISA
Entity type:Individual
Prefix:
First Name:MARRISA
Middle Name:
Last Name:MODELL
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10958 OAK LN APT 6216
Mailing Address - Street 2:
Mailing Address - City:VAN BUREN TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48111-4377
Mailing Address - Country:US
Mailing Address - Phone:734-720-2933
Mailing Address - Fax:
Practice Address - Street 1:43825 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48188-2551
Practice Address - Country:US
Practice Address - Phone:734-397-3088
Practice Address - Fax:734-397-0078
Is Sole Proprietor?:No
Enumeration Date:2024-12-09
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program