Provider Demographics
NPI:1235376997
Name:FEDAK, LARISSA ANN (EDD CCC-SLP BCBA-D)
Entity Type:Individual
Prefix:DR
First Name:LARISSA
Middle Name:ANN
Last Name:FEDAK
Suffix:
Gender:F
Credentials:EDD CCC-SLP BCBA-D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4452 US HIGHWAY 421
Mailing Address - Street 2:
Mailing Address - City:PENNINGTON GAP
Mailing Address - State:VA
Mailing Address - Zip Code:24277-7972
Mailing Address - Country:US
Mailing Address - Phone:855-832-6727
Mailing Address - Fax:772-675-9100
Practice Address - Street 1:155 MAIN DUNSTABLE RD STE 150
Practice Address - Street 2:
Practice Address - City:NASHUA
Practice Address - State:NH
Practice Address - Zip Code:03060-3640
Practice Address - Country:US
Practice Address - Phone:603-660-6306
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-16
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ41YS00572200235Z00000X
NY018241235Z00000X
1-11-8515103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1-11-8515OtherBCBA-D
NJ1235376997Medicaid