Provider Demographics
NPI:1952701484
Name:RONEY, LARISSA ALEXANDRA (DPT)
Entity type:Individual
Prefix:
First Name:LARISSA
Middle Name:ALEXANDRA
Last Name:RONEY
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:LARISSA
Other - Middle Name:ALEXANDRA
Other - Last Name:DOBROWOLSKY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:4934 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515-3611
Mailing Address - Country:US
Mailing Address - Phone:630-964-4008
Mailing Address - Fax:630-964-4117
Practice Address - Street 1:4934 MAIN ST
Practice Address - Street 2:
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-3611
Practice Address - Country:US
Practice Address - Phone:630-964-4008
Practice Address - Fax:630-964-4117
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-03
Last Update Date:2024-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.021045225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist