Provider Demographics
NPI:1043096506
Name:HALL, LARRISA JO
Entity Type:Individual
Prefix:
First Name:LARRISA
Middle Name:JO
Last Name:HALL
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:LARRISA
Other - Middle Name:JO
Other - Last Name:WILTROUT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3282 S PACIFIC HWY APT 12
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97501-8771
Mailing Address - Country:US
Mailing Address - Phone:458-262-1008
Mailing Address - Fax:
Practice Address - Street 1:300 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97501-2756
Practice Address - Country:US
Practice Address - Phone:541-772-1777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-31
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)