Provider Demographics
NPI:1346372448
Name:STEWART, LARISSA (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:LARISSA
Middle Name:
Last Name:STEWART
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 ANDERSON ST
Mailing Address - Street 2:
Mailing Address - City:LEAD
Mailing Address - State:SD
Mailing Address - Zip Code:57754-1402
Mailing Address - Country:US
Mailing Address - Phone:605-641-3156
Mailing Address - Fax:
Practice Address - Street 1:210 ANDERSON ST
Practice Address - Street 2:
Practice Address - City:LEAD
Practice Address - State:SD
Practice Address - Zip Code:57754-1402
Practice Address - Country:US
Practice Address - Phone:605-641-3156
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2010-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5836293Medicaid