Provider Demographics
NPI:1700120219
Name:CORLISS, ROOPA MELGIRI (PT)
Entity type:Individual
Prefix:
First Name:ROOPA
Middle Name:MELGIRI
Last Name:CORLISS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3901 HOYT AVE
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-4918
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3927 RUCKER AVE
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-4833
Practice Address - Country:US
Practice Address - Phone:425-339-5419
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-21
Last Update Date:2013-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00009332225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2023715Medicaid
WA2023715Medicaid