Provider Demographics
NPI:1477640894
Name:RICKENBACH, MARISA LYNN (MSPT)
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:LYNN
Last Name:RICKENBACH
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:MARISA
Other - Middle Name:LYNN
Other - Last Name:RYAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSPT
Mailing Address - Street 1:4081 E SANTA FE LN
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85297-8034
Mailing Address - Country:US
Mailing Address - Phone:480-656-4808
Mailing Address - Fax:
Practice Address - Street 1:20261 E OCOTILLO RD
Practice Address - Street 2:SUITE 110
Practice Address - City:QUEEN CREEK
Practice Address - State:AZ
Practice Address - Zip Code:85242-8806
Practice Address - Country:US
Practice Address - Phone:480-677-2771
Practice Address - Fax:480-677-2768
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2009-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01208100225100000X
AZ7092225100000X
PAPT017984225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist