Provider Demographics
NPI:1982930822
Name:TAVARONE, CARISSA (MPS,PT)
Entity Type:Individual
Prefix:
First Name:CARISSA
Middle Name:
Last Name:TAVARONE
Suffix:
Gender:F
Credentials:MPS,PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NORTH SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13212-1735
Mailing Address - Country:US
Mailing Address - Phone:315-452-5580
Mailing Address - Fax:315-452-5303
Practice Address - Street 1:401 N MAIN ST
Practice Address - Street 2:
Practice Address - City:NORTH SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13212-1735
Practice Address - Country:US
Practice Address - Phone:315-452-5580
Practice Address - Fax:315-452-5303
Is Sole Proprietor?:No
Enumeration Date:2009-10-28
Last Update Date:2009-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018785-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist