Provider Demographics
NPI:1083154363
Name:BRISITA, MARILENI (PT, DPT)
Entity Type:Individual
Prefix:
First Name:MARILENI
Middle Name:
Last Name:BRISITA
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 1:5958 ROUTE 25A
Mailing Address - Street 2:
Mailing Address - City:WADING RIVER
Mailing Address - State:NY
Mailing Address - Zip Code:11792-2001
Mailing Address - Country:US
Mailing Address - Phone:631-929-8200
Mailing Address - Fax:
Practice Address - Street 1:47 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06107-1926
Practice Address - Country:US
Practice Address - Phone:860-409-4595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-06
Last Update Date:2019-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY041342-1225100000X
CT225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist