Provider Demographics
NPI:1235651878
Name:SUBSARA, CLARISSA LIRIO (MSOT)
Entity Type:Individual
Prefix:MRS
First Name:CLARISSA
Middle Name:LIRIO
Last Name:SUBSARA
Suffix:
Gender:F
Credentials:MSOT
Other - Prefix:
Other - First Name:CLARISSA
Other - Middle Name:DE LEON
Other - Last Name:LIRIO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 255228
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95865-5228
Mailing Address - Country:US
Mailing Address - Phone:916-708-8038
Mailing Address - Fax:
Practice Address - Street 1:1680 E ROSEVILLE PKWY STE 112
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-3988
Practice Address - Country:US
Practice Address - Phone:916-746-3474
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-14
Last Update Date:2022-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13367225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist