Provider Demographics
NPI:1083112106
Name:DESJARDINS, MARISSA LYNN (PT, DPT)
Entity Type:Individual
Prefix:MRS
First Name:MARISSA
Middle Name:LYNN
Last Name:DESJARDINS
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 1:8240 W. CACTUS RD. OAKESON PHYSICAL THERAPY
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381
Mailing Address - Country:US
Mailing Address - Phone:623-878-9696
Mailing Address - Fax:623-776-0668
Practice Address - Street 1:8240 W. CACTUS RD. OAKESON PHYSICAL THERAPY
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381
Practice Address - Country:US
Practice Address - Phone:623-878-9696
Practice Address - Fax:623-776-0668
Is Sole Proprietor?:No
Enumeration Date:2018-01-23
Last Update Date:2020-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6532225100000X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ388526Medicaid