Provider Demographics
NPI:1285494062
Name:HOLLOWAY, MARISSA FAITH (MAT, ATC)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:FAITH
Last Name:HOLLOWAY
Suffix:
Gender:F
Credentials:MAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7741 NEW SALEM ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92126-2042
Mailing Address - Country:US
Mailing Address - Phone:858-531-7356
Mailing Address - Fax:
Practice Address - Street 1:1500 SAN PABLO ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-5313
Practice Address - Country:US
Practice Address - Phone:800-872-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-20
Last Update Date:2025-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X2255A2300X, 2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer