Provider Demographics
NPI:1104008101
Name:DE LA ROSA, MARISOL
Entity Type:Individual
Prefix:MRS
First Name:MARISOL
Middle Name:
Last Name:DE LA ROSA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1316 E ELLICOTT ST
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33603-2532
Mailing Address - Country:US
Mailing Address - Phone:813-232-5852
Mailing Address - Fax:813-232-5852
Practice Address - Street 1:1316 E ELLICOTT ST
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33603-2532
Practice Address - Country:US
Practice Address - Phone:813-232-5852
Practice Address - Fax:813-232-5852
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-30
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist