Provider Demographics
NPI:1851484117
Name:DEROSA, MARLENE MARIE (PT)
Entity Type:Individual
Prefix:
First Name:MARLENE
Middle Name:MARIE
Last Name:DEROSA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3285 S SKYE WAY
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-9142
Mailing Address - Country:US
Mailing Address - Phone:928-774-6626
Mailing Address - Fax:928-214-3277
Practice Address - Street 1:1485 N TURQUOISE DR
Practice Address - Street 2:SUITE 220
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-1398
Practice Address - Country:US
Practice Address - Phone:928-774-6626
Practice Address - Fax:928-214-3277
Is Sole Proprietor?:No
Enumeration Date:2006-10-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ766225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ782400001OtherAHCCCS NUMBER
AZ782400001OtherAHCCCS NUMBER