Provider Demographics
NPI:1073391124
Name:THEISON, LARISSA (LCSW, LSCSW)
Entity Type:Individual
Prefix:
First Name:LARISSA
Middle Name:
Last Name:THEISON
Suffix:
Gender:F
Credentials:LCSW, LSCSW
Other - Prefix:
Other - First Name:LARISSA
Other - Middle Name:
Other - Last Name:HAGGARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW, LSCSW
Mailing Address - Street 1:4909 HARKNESS AVE
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64136-1326
Mailing Address - Country:US
Mailing Address - Phone:816-916-5001
Mailing Address - Fax:
Practice Address - Street 1:4909 HARKNESS AVE
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64136-1326
Practice Address - Country:US
Practice Address - Phone:816-916-5001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-19
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20100390621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical