Provider Demographics
NPI:1053579250
Name:NEAL, LARISSA GIZELLE
Entity type:Individual
Prefix:MRS
First Name:LARISSA
Middle Name:GIZELLE
Last Name:NEAL
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 1:44863 MILESTONE SQ
Mailing Address - Street 2:302
Mailing Address - City:ASHBURN
Mailing Address - State:VA
Mailing Address - Zip Code:20147-4203
Mailing Address - Country:US
Mailing Address - Phone:703-729-7311
Mailing Address - Fax:
Practice Address - Street 1:1640 REDSTONE CENTER DR
Practice Address - Street 2:200
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84098-7605
Practice Address - Country:US
Practice Address - Phone:888-800-8744
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-26
Last Update Date:2008-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA23052049032251G0304X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics