Provider Demographics
NPI:1023367836
Name:KING, CARISSA LEIGH (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:CARISSA
Middle Name:LEIGH
Last Name:KING
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17233 N HOLMES BLVD
Mailing Address - Street 2:STE. 1650
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85053-2018
Mailing Address - Country:US
Mailing Address - Phone:602-547-1836
Mailing Address - Fax:602-547-2806
Practice Address - Street 1:17233 N HOLMES BLVD
Practice Address - Street 2:STE 1650
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85053-2018
Practice Address - Country:US
Practice Address - Phone:602-547-1836
Practice Address - Fax:602-547-2806
Is Sole Proprietor?:No
Enumeration Date:2012-09-07
Last Update Date:2017-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ9966225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist