Provider Demographics
NPI:1730720277
Name:LARIOSA, CHARISMA (PT)
Entity type:Individual
Prefix:MRS
First Name:CHARISMA
Middle Name:
Last Name:LARIOSA
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 1:3724 N RUTHERFORD AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60634-2392
Mailing Address - Country:US
Mailing Address - Phone:773-698-5584
Mailing Address - Fax:708-776-7816
Practice Address - Street 1:3724 N RUTHERFORD AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60634-2392
Practice Address - Country:US
Practice Address - Phone:773-698-5584
Practice Address - Fax:708-776-7816
Is Sole Proprietor?:No
Enumeration Date:2019-10-07
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070012507225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist