Provider Demographics
NPI:1942796529
Name:BALISI, ROSHELLE VENEGAS (PTA)
Entity Type:Individual
Prefix:
First Name:ROSHELLE
Middle Name:VENEGAS
Last Name:BALISI
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:94-790 KAAKA ST
Mailing Address - Street 2:
Mailing Address - City:WAIPAHU
Mailing Address - State:HI
Mailing Address - Zip Code:96797-1298
Mailing Address - Country:US
Mailing Address - Phone:808-225-8604
Mailing Address - Fax:
Practice Address - Street 1:2226 LILIHA ST STE 304
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96817-1605
Practice Address - Country:US
Practice Address - Phone:808-547-6500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-06
Last Update Date:2018-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI298225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty