Provider Demographics
NPI:1801294921
Name:LAROSSA, VICKI (OTR/L)
Entity type:Individual
Prefix:
First Name:VICKI
Middle Name:
Last Name:LAROSSA
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:132 WINDWARD DR
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777-2331
Mailing Address - Country:US
Mailing Address - Phone:516-848-6845
Mailing Address - Fax:631-473-4215
Practice Address - Street 1:132 WINDWARD DR
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-2331
Practice Address - Country:US
Practice Address - Phone:516-848-6845
Practice Address - Fax:631-473-4215
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-06
Last Update Date:2014-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008129225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist