Provider Demographics
NPI:1831533371
Name:ROMAN, CHERISSE (PT, DPT)
Entity type:Individual
Prefix:DR
First Name:CHERISSE
Middle Name:
Last Name:ROMAN
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 BEAL PKWY NW
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32548-4333
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:195 MATTIE M KELLY BLVD
Practice Address - Street 2:
Practice Address - City:DESTIN
Practice Address - State:FL
Practice Address - Zip Code:32541-2811
Practice Address - Country:US
Practice Address - Phone:850-650-2423
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-26
Last Update Date:2013-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT255382251G0304X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics