Healthcare Provider Details

I. General information

NPI: 1154028934
Provider Name (Legal Business Name): KRISTINE ALYSSE RICOSSA OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2023
Last Update Date: 02/13/2023
Certification Date: 02/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

975 SERENO DR
VALLEJO CA
94589-2441
US

IV. Provider business mailing address

730 CARNATION DR
VACAVILLE CA
95687-8268
US

V. Phone/Fax

Practice location:
  • Phone: 707-651-1000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0019X
TaxonomyPhysical Rehabilitation Occupational Therapist
License Number24198
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: