Provider Demographics
NPI:1154363422
Name:RISORTO, SOPHIA A (PT)
Entity type:Individual
Prefix:
First Name:SOPHIA
Middle Name:A
Last Name:RISORTO
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 1:68860 PEREZ RD STE E2
Mailing Address - Street 2:
Mailing Address - City:CATHEDRAL CITY
Mailing Address - State:CA
Mailing Address - Zip Code:92234-7248
Mailing Address - Country:US
Mailing Address - Phone:760-770-6651
Mailing Address - Fax:760-770-6651
Practice Address - Street 1:68860 PEREZ RD STE E2
Practice Address - Street 2:
Practice Address - City:CATHEDRAL CITY
Practice Address - State:CA
Practice Address - Zip Code:92234-7248
Practice Address - Country:US
Practice Address - Phone:760-770-6651
Practice Address - Fax:760-770-6651
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT120932251G0304X
WI105842251G0304X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6045270001Medicare NSC
CA0PT120931Medicare ID - Type Unspecified