Provider Demographics
NPI:1538545108
Name:GRASSANO, MARYALICIA (PT, DPT)
Entity type:Individual
Prefix:
First Name:MARYALICIA
Middle Name:
Last Name:GRASSANO
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:MARYALICIA
Other - Middle Name:
Other - Last Name:KOHUT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:PO BOX 412307 SUITE 101
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-3171
Mailing Address - Country:US
Mailing Address - Phone:914-294-4050
Mailing Address - Fax:631-760-8306
Practice Address - Street 1:968 FIRST COLONIAL RD
Practice Address - Street 2:SUITE 101
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-3171
Practice Address - Country:US
Practice Address - Phone:757-412-1005
Practice Address - Fax:757-412-1015
Is Sole Proprietor?:No
Enumeration Date:2015-08-06
Last Update Date:2021-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305209667225100000X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist