Healthcare Provider Details

I. General information

NPI: 1649041906
Provider Name (Legal Business Name): LARISSA RAE ROSANO PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/15/2024
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

765 N 114TH AVE STE 101
AVONDALE AZ
85323-5003
US

IV. Provider business mailing address

2108 E THOMAS RD
PHOENIX AZ
85016-7761
US

V. Phone/Fax

Practice location:
  • Phone: 602-933-7778
  • Fax: 602-933-4296
Mailing address:
  • Phone: 602-933-3124
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberCP043178T
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberLPT033442
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: