Provider Demographics
NPI:1649364654
Name:CORREDERA, ROSA (LMT PTA)
Entity type:Individual
Prefix:
First Name:ROSA
Middle Name:
Last Name:CORREDERA
Suffix:
Gender:F
Credentials:LMT PTA
Other - Prefix:
Other - First Name:ROSA
Other - Middle Name:CORREDERA
Other - Last Name:LECKLITNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMT PTA
Mailing Address - Street 1:5076 3RD ROAD
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33467
Mailing Address - Country:US
Mailing Address - Phone:561-439-0102
Mailing Address - Fax:
Practice Address - Street 1:5076 3RD ROAD
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33467
Practice Address - Country:US
Practice Address - Phone:561-439-0102
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL20137225200000X
FL15407225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Not Answered225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist