Provider Demographics
NPI:1073906079
Name:MARTIN, LARISSA LYNN (DC)
Entity Type:Individual
Prefix:DR
First Name:LARISSA
Middle Name:LYNN
Last Name:MARTIN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:DR
Other - First Name:LARISSA
Other - Middle Name:LYNN
Other - Last Name:SEVERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:2360 STATE ROUTE 89
Mailing Address - Street 2:
Mailing Address - City:SENECA FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:13148-9460
Mailing Address - Country:US
Mailing Address - Phone:315-568-3166
Mailing Address - Fax:
Practice Address - Street 1:2360 STATE ROUTE 89
Practice Address - Street 2:
Practice Address - City:SENECA FALLS
Practice Address - State:NY
Practice Address - Zip Code:13148-9460
Practice Address - Country:US
Practice Address - Phone:315-568-3166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-15
Last Update Date:2018-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012526111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor