Provider Demographics
NPI:1215381736
Name:LARISON, NANCY G (LCCS)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:G
Last Name:LARISON
Suffix:
Gender:F
Credentials:LCCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:504 W 29TH STREET
Mailing Address - Street 2:LA FRONTERA CENTER, INC.
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85713
Mailing Address - Country:US
Mailing Address - Phone:520-884-9920
Mailing Address - Fax:
Practice Address - Street 1:504 W 29TH STREET
Practice Address - Street 2:LA FRONTERA CENTER, INC.
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85713
Practice Address - Country:US
Practice Address - Phone:520-884-9920
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-21
Last Update Date:2016-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW 1634101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional