Provider Demographics
NPI:1780837310
Name:GILES, LARISSA (LPTA)
Entity Type:Individual
Prefix:
First Name:LARISSA
Middle Name:
Last Name:GILES
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40778 BOYD RD
Mailing Address - Street 2:
Mailing Address - City:WELLSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43968-9707
Mailing Address - Country:US
Mailing Address - Phone:330-532-4937
Mailing Address - Fax:
Practice Address - Street 1:7233 WHIPPLE AVE NW
Practice Address - Street 2:
Practice Address - City:NORTH CANTON
Practice Address - State:OH
Practice Address - Zip Code:44720-7137
Practice Address - Country:US
Practice Address - Phone:330-498-8200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-28
Last Update Date:2008-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPTA 7081225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant