Provider Demographics
NPI:1356391536
Name:LATOURETTE, LISA GORDON (MSPT)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:GORDON
Last Name:LATOURETTE
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:DYANN
Other - Last Name:GORDON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSPT
Mailing Address - Street 1:8575 RIXLEW LN
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20109-3701
Mailing Address - Country:US
Mailing Address - Phone:703-257-3364
Mailing Address - Fax:
Practice Address - Street 1:8575 RIXLEW LN
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20109-3701
Practice Address - Country:US
Practice Address - Phone:703-257-3364
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2011-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305203147225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist