Provider Demographics
NPI:1033553581
Name:HYDE, LARISSA JANEL
Entity Type:Individual
Prefix:MS
First Name:LARISSA
Middle Name:JANEL
Last Name:HYDE
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:LARISSA
Other - Middle Name:JANEL
Other - Last Name:HYDE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS, OTR/L
Mailing Address - Street 1:4 COUNTRYWOOD CT
Mailing Address - Street 2:
Mailing Address - City:DEER PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11729-5602
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4 COUNTRYWOOD CT
Practice Address - Street 2:
Practice Address - City:DEER PARK
Practice Address - State:NY
Practice Address - Zip Code:11729-5602
Practice Address - Country:US
Practice Address - Phone:516-984-0971
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-26
Last Update Date:2013-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015356225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist