Provider Demographics
NPI:1912278730
Name:TILLEY, LARISSA MARIE (DC)
Entity Type:Individual
Prefix:DR
First Name:LARISSA
Middle Name:MARIE
Last Name:TILLEY
Suffix:
Gender:F
Credentials:DC
Other - Prefix:DR
Other - First Name:LARISSA
Other - Middle Name:MARIE
Other - Last Name:CAMPITELLI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:4774 MUNSON ST NW
Mailing Address - Street 2:SUITE 302
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718-3634
Mailing Address - Country:US
Mailing Address - Phone:330-494-0422
Mailing Address - Fax:330-494-3601
Practice Address - Street 1:4774 MUNSON ST NW
Practice Address - Street 2:SUITE 302
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44718-3634
Practice Address - Country:US
Practice Address - Phone:330-494-0422
Practice Address - Fax:330-494-3601
Is Sole Proprietor?:No
Enumeration Date:2012-01-25
Last Update Date:2013-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012002407111N00000X
TN2595111N00000X
OH4404111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor