Provider Demographics
NPI:1619638624
Name:VAN KOPPEN, MARISSA LYNN (MS, CCC-SLP, CBIS)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:LYNN
Last Name:VAN KOPPEN
Suffix:
Gender:F
Credentials:MS, CCC-SLP, CBIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 WEBSTER AVE # 1
Mailing Address - Street 2:
Mailing Address - City:SEASIDE HEIGHTS
Mailing Address - State:NJ
Mailing Address - Zip Code:08751-2334
Mailing Address - Country:US
Mailing Address - Phone:973-865-5404
Mailing Address - Fax:
Practice Address - Street 1:2145 WHITESVILLE RD
Practice Address - Street 2:
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08755-1175
Practice Address - Country:US
Practice Address - Phone:973-865-5404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-03
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ41YS01011300235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist