Provider Demographics
NPI:1790310688
Name:LEAL, MARISA
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:
Last Name:LEAL
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 1:5065 ARBOR GLEN CIR
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33463-8042
Mailing Address - Country:US
Mailing Address - Phone:954-778-1764
Mailing Address - Fax:
Practice Address - Street 1:301 CRAWFORD BLVD STE 103
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33432-3762
Practice Address - Country:US
Practice Address - Phone:561-395-9920
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-11
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL4130171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist