Provider Demographics
NPI:1083881601
Name:LAROSA, HEIDI A (PT)
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:A
Last Name:LAROSA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12830 WEST PEACHTREE DR
Mailing Address - Street 2:
Mailing Address - City:NEW BERLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53151
Mailing Address - Country:US
Mailing Address - Phone:414-858-9706
Mailing Address - Fax:
Practice Address - Street 1:12830 W PEACHTREE DR
Practice Address - Street 2:
Practice Address - City:NEW BERLIN
Practice Address - State:WI
Practice Address - Zip Code:53151-7623
Practice Address - Country:US
Practice Address - Phone:414-858-9706
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-13
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5565-024172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker