Provider Demographics
NPI:1053042242
Name:KIBORT, LARISSA EMILY (CADC)
Entity Type:Individual
Prefix:
First Name:LARISSA
Middle Name:EMILY
Last Name:KIBORT
Suffix:
Gender:F
Credentials:CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24341 CONEJO APT 4
Mailing Address - Street 2:
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92656-3144
Mailing Address - Country:US
Mailing Address - Phone:708-446-1162
Mailing Address - Fax:
Practice Address - Street 1:34185 VIOLET LANTERN ST UNIT 103
Practice Address - Street 2:
Practice Address - City:DANA POINT
Practice Address - State:CA
Practice Address - Zip Code:92629-2508
Practice Address - Country:US
Practice Address - Phone:949-356-7952
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-20
Last Update Date:2022-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACI35830622101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)