Healthcare Provider Details

I. General information

NPI: 1659058121
Provider Name (Legal Business Name): MARISA VISCO DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2023
Last Update Date: 04/29/2026
Certification Date: 04/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

285 GOVERNOR ST
PROVIDENCE RI
02906-3237
US

IV. Provider business mailing address

5840 CORPORATE WAY STE 101
WEST PALM BEACH FL
33407-2040
US

V. Phone/Fax

Practice location:
  • Phone: 401-276-0800
  • Fax:
Mailing address:
  • Phone: 561-432-0111
  • Fax: 561-432-1075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT39813
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number40QA02146600
License Number StateNJ
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT04104
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: