Provider Demographics
NPI:1548814130
Name:PITCHKOLAN, LARISA ITO
Entity type:Individual
Prefix:
First Name:LARISA
Middle Name:ITO
Last Name:PITCHKOLAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 E SCHUSTER AVE STE 8
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79902-4360
Mailing Address - Country:US
Mailing Address - Phone:915-533-1799
Mailing Address - Fax:915-267-3553
Practice Address - Street 1:615 E SCHUSTER AVE STE 8
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79902-4360
Practice Address - Country:US
Practice Address - Phone:915-533-1799
Practice Address - Fax:915-267-3553
Is Sole Proprietor?:No
Enumeration Date:2019-07-31
Last Update Date:2019-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1090777225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist