Provider Demographics
NPI:1235888462
Name:VALERO ZAVALA, LARISSA G (M ED)
Entity Type:Individual
Prefix:
First Name:LARISSA
Middle Name:G
Last Name:VALERO ZAVALA
Suffix:
Gender:F
Credentials:M ED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1137
Mailing Address - Street 2:
Mailing Address - City:THIBODAUX
Mailing Address - State:LA
Mailing Address - Zip Code:70302-1137
Mailing Address - Country:US
Mailing Address - Phone:985-447-7905
Mailing Address - Fax:985-447-7907
Practice Address - Street 1:120 CONVENT STREET
Practice Address - Street 2:
Practice Address - City:LABADIEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70372
Practice Address - Country:US
Practice Address - Phone:985-446-6833
Practice Address - Fax:985-446-6835
Is Sole Proprietor?:No
Enumeration Date:2022-03-23
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAL-617103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst