Provider Demographics
NPI:1861577199
Name:ROSSOW, CORISSA MICHELE (PT, MPT)
Entity type:Individual
Prefix:MRS
First Name:CORISSA
Middle Name:MICHELE
Last Name:ROSSOW
Suffix:
Gender:F
Credentials:PT, MPT
Other - Prefix:MISS
Other - First Name:CORISSA
Other - Middle Name:MICHELE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:236 PASSENDALE LN
Mailing Address - Street 2:
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77845-4060
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1318 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802-5215
Practice Address - Country:US
Practice Address - Phone:979-776-2872
Practice Address - Fax:979-776-1456
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2009-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1155409225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist