Provider Demographics
NPI:1801373113
Name:TRACH, LARISA HELENE (PT, DPT, CSCS)
Entity type:Individual
Prefix:
First Name:LARISA
Middle Name:HELENE
Last Name:TRACH
Suffix:
Gender:F
Credentials:PT, DPT, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:880 6TH ST S
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33701-4827
Mailing Address - Country:US
Mailing Address - Phone:727-767-3253
Mailing Address - Fax:
Practice Address - Street 1:880 6TH ST S
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-4827
Practice Address - Country:US
Practice Address - Phone:727-767-3253
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-19
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD26999225100000X
FLPT34060225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist