Provider Demographics
NPI:1184198418
Name:MANZO, LARISA AYN (BCBA)
Entity Type:Individual
Prefix:
First Name:LARISA
Middle Name:AYN
Last Name:MANZO
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 DOUGLAS RD
Mailing Address - Street 2:SUITE 230
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33134-7807
Mailing Address - Country:US
Mailing Address - Phone:854-844-1116
Mailing Address - Fax:
Practice Address - Street 1:3855 CENTERVIEW DR STE 400B
Practice Address - Street 2:
Practice Address - City:CHANTILLY
Practice Address - State:VA
Practice Address - Zip Code:20151-3285
Practice Address - Country:US
Practice Address - Phone:854-844-1116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-21
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0133001741103K00000X, 103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst