Provider Demographics
NPI:1316583933
Name:CAMACHO, LARISSA (DPT, CFPS)
Entity Type:Individual
Prefix:DR
First Name:LARISSA
Middle Name:
Last Name:CAMACHO
Suffix:
Gender:F
Credentials:DPT, CFPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:269 JAMAICA AVE
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11763-3271
Mailing Address - Country:US
Mailing Address - Phone:321-830-5521
Mailing Address - Fax:
Practice Address - Street 1:273 MORICHES RD
Practice Address - Street 2:
Practice Address - City:SAINT JAMES
Practice Address - State:NY
Practice Address - Zip Code:11780-2117
Practice Address - Country:US
Practice Address - Phone:631-862-8990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-19
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY04508801225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist