Provider Demographics
NPI:1114946886
Name:HORNER, LARISSA L (PT)
Entity Type:Individual
Prefix:
First Name:LARISSA
Middle Name:L
Last Name:HORNER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 JACKSON PIKE
Mailing Address - Street 2:
Mailing Address - City:GALLIPOLIS
Mailing Address - State:OH
Mailing Address - Zip Code:45631-1560
Mailing Address - Country:US
Mailing Address - Phone:740-441-1934
Mailing Address - Fax:740-446-5982
Practice Address - Street 1:98 STATE ST
Practice Address - Street 2:
Practice Address - City:PROCTORVILLE
Practice Address - State:OH
Practice Address - Zip Code:45669-8163
Practice Address - Country:US
Practice Address - Phone:740-886-9403
Practice Address - Fax:740-446-5153
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2010-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH068615225100000X
WV006815225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
650019667OtherRR MEDICARE
OH2221287OtherMOLINA MEDICAID
WV0157960000Medicaid
OH000000204524OtherOH MEDICAID UNISON
000000217253OtherANTHEM BCBS
OH2221287Medicaid
OH2221287Medicaid