Provider Demographics
NPI:1821290578
Name:ROSE, MARISA (MS, PT, SCS, ATC)
Entity Type:Individual
Prefix:MS
First Name:MARISA
Middle Name:
Last Name:ROSE
Suffix:
Gender:F
Credentials:MS, PT, SCS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 5TH AVE
Mailing Address - Street 2:APT 11R
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10011-8838
Mailing Address - Country:US
Mailing Address - Phone:917-324-5358
Mailing Address - Fax:212-656-1874
Practice Address - Street 1:2 5TH AVE
Practice Address - Street 2:APT 11R
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10011-8838
Practice Address - Country:US
Practice Address - Phone:917-324-5358
Practice Address - Fax:212-656-1874
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-04
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021465261QP2000X
NY02146512251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY205093704Medicare UPIN