Provider Demographics
NPI:1295843571
Name:MCMAHON, LARISSA ALEXANDRA (DC)
Entity Type:Individual
Prefix:DR
First Name:LARISSA
Middle Name:ALEXANDRA
Last Name:MCMAHON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39525 W 14 MILE RD
Mailing Address - Street 2:STE 100
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48377-1635
Mailing Address - Country:US
Mailing Address - Phone:248-242-2123
Mailing Address - Fax:
Practice Address - Street 1:3355 UNION LAKE RD
Practice Address - Street 2:
Practice Address - City:COMMERCE TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48382-4551
Practice Address - Country:US
Practice Address - Phone:248-242-2123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2019-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301008198111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA950F33490OtherBCBS
MION37160Medicare ID - Type UnspecifiedMEDICARE
MIU87128Medicare UPIN