Provider Demographics
NPI:1902498827
Name:KHALIFA, MARISSA
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:KHALIFA
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 1:8366 18 MILE RD APT 104
Mailing Address - Street 2:
Mailing Address - City:STERLING HTS
Mailing Address - State:MI
Mailing Address - Zip Code:48313-3031
Mailing Address - Country:US
Mailing Address - Phone:158-658-8562
Mailing Address - Fax:
Practice Address - Street 1:39393 VAN DYKE AVE STE 105
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48313-4636
Practice Address - Country:US
Practice Address - Phone:586-722-7524
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-11
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI82546225800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist