Provider Demographics
NPI:1366771776
Name:DEROSE, CAROLINA MESA (PT)
Entity type:Individual
Prefix:MRS
First Name:CAROLINA
Middle Name:MESA
Last Name:DEROSE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MISS
Other - First Name:CAROLINA
Other - Middle Name:MESA
Other - Last Name:LIZARAZO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:325 BUCKEYE LN
Mailing Address - Street 2:
Mailing Address - City:WEST CHESTER
Mailing Address - State:PA
Mailing Address - Zip Code:19382-6119
Mailing Address - Country:US
Mailing Address - Phone:757-645-8368
Mailing Address - Fax:
Practice Address - Street 1:780 W LINCOLN HWY
Practice Address - Street 2:
Practice Address - City:EXTON
Practice Address - State:PA
Practice Address - Zip Code:19341-2547
Practice Address - Country:US
Practice Address - Phone:610-873-4856
Practice Address - Fax:610-873-4859
Is Sole Proprietor?:No
Enumeration Date:2009-12-14
Last Update Date:2009-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT0199232251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic