Provider Demographics
NPI:1831061647
Name:BRINK, MARISSA ASHLEY (MSOTRL)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:ASHLEY
Last Name:BRINK
Suffix:
Gender:F
Credentials:MSOTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:198 BARNEY ST
Mailing Address - Street 2:
Mailing Address - City:WILKES BARRE
Mailing Address - State:PA
Mailing Address - Zip Code:18702-3414
Mailing Address - Country:US
Mailing Address - Phone:570-637-7935
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 43
Practice Address - Street 2:
Practice Address - City:FACTORYVILLE
Practice Address - State:PA
Practice Address - Zip Code:18419-0043
Practice Address - Country:US
Practice Address - Phone:570-561-6639
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-22
Last Update Date:2025-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC021080225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics