Healthcare Provider Details

I. General information

NPI: 1831239961
Provider Name (Legal Business Name): LISA F MCLEOD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 12/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 ASHBY ST
ALEXANDRIA VA
22305-2902
US

IV. Provider business mailing address

209 ASHBY ST
ALEXANDRIA VA
22305-2902
US

V. Phone/Fax

Practice location:
  • Phone: 703-837-1138
  • Fax: 703-837-1138
Mailing address:
  • Phone: 703-837-1138
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number30546-01
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: