Provider Demographics
NPI:1821394040
Name:CAROSI, DESIRAE MARIE (LMT)
Entity Type:Individual
Prefix:
First Name:DESIRAE
Middle Name:MARIE
Last Name:CAROSI
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 VLY RD
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12205-2229
Mailing Address - Country:US
Mailing Address - Phone:518-320-4784
Mailing Address - Fax:
Practice Address - Street 1:1719 CENTRAL AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12205-4761
Practice Address - Country:US
Practice Address - Phone:518-452-1654
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-05
Last Update Date:2011-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY27023045225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist