Provider Demographics
NPI:1427425230
Name:DEARISO, FOSTER (PT, DPT, ATC, LAT)
Entity type:Individual
Prefix:
First Name:FOSTER
Middle Name:
Last Name:DEARISO
Suffix:
Gender:M
Credentials:PT, DPT, ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1955 NOCTURNE DR UNIT 3410
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30009-4830
Mailing Address - Country:US
Mailing Address - Phone:478-696-2483
Mailing Address - Fax:
Practice Address - Street 1:1955 NOCTURNE DR UNIT 3410
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30009-4830
Practice Address - Country:US
Practice Address - Phone:478-696-2483
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-27
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0027842255A2300X
GAPT016487225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer