Provider Demographics
NPI:1073033783
Name:WILLIAMS, LARISSA ELLIS (LMT)
Entity Type:Individual
Prefix:
First Name:LARISSA
Middle Name:ELLIS
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:LARISSA
Other - Middle Name:
Other - Last Name:ELLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1706
Mailing Address - Street 2:
Mailing Address - City:VALDEZ
Mailing Address - State:AK
Mailing Address - Zip Code:99686-1706
Mailing Address - Country:US
Mailing Address - Phone:907-835-8777
Mailing Address - Fax:907-835-8702
Practice Address - Street 1:501 E. BREMNER
Practice Address - Street 2:
Practice Address - City:VALDEZ
Practice Address - State:AK
Practice Address - Zip Code:99686-1706
Practice Address - Country:US
Practice Address - Phone:907-835-8777
Practice Address - Fax:907-835-8702
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-23
Last Update Date:2017-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK101615225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist