Provider Demographics
NPI:1811411887
Name:STACY, LARISSA (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:LARISSA
Middle Name:
Last Name:STACY
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:414 PENCO RD
Mailing Address - Street 2:
Mailing Address - City:WEIRTON
Mailing Address - State:WV
Mailing Address - Zip Code:26062-3822
Mailing Address - Country:US
Mailing Address - Phone:304-393-4072
Mailing Address - Fax:
Practice Address - Street 1:47454 ROUTE 52
Practice Address - Street 2:
Practice Address - City:KERMIT
Practice Address - State:WV
Practice Address - Zip Code:25674-8052
Practice Address - Country:US
Practice Address - Phone:304-393-4072
Practice Address - Fax:304-393-4074
Is Sole Proprietor?:No
Enumeration Date:2017-08-01
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY007169225100000X
WVCP004549T225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist