Provider Demographics
NPI:1275196123
Name:SOTO BRIONES, LARISA SCHANNEL
Entity Type:Individual
Prefix:
First Name:LARISA
Middle Name:SCHANNEL
Last Name:SOTO BRIONES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19828 WHEELWRIGHT DR
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20886-1049
Mailing Address - Country:US
Mailing Address - Phone:301-674-6733
Mailing Address - Fax:
Practice Address - Street 1:7613 STANDISH PL
Practice Address - Street 2:
Practice Address - City:DERWOOD
Practice Address - State:MD
Practice Address - Zip Code:20855-2702
Practice Address - Country:US
Practice Address - Phone:240-672-0330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-17
Last Update Date:2019-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
MDS-316-488-760-734106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No101Y00000XBehavioral Health & Social Service ProvidersCounselor