Provider Demographics
NPI:1417260886
Name:LASKA-RUEBUSCH, LARISSA (PSYD)
Entity Type:Individual
Prefix:
First Name:LARISSA
Middle Name:
Last Name:LASKA-RUEBUSCH
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:LARISSA
Other - Middle Name:
Other - Last Name:LASKA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:245 KENTUCKY ST.
Mailing Address - Street 2:SUITE A
Mailing Address - City:PATALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94952
Mailing Address - Country:US
Mailing Address - Phone:707-216-1612
Mailing Address - Fax:
Practice Address - Street 1:245 KENTUCKY ST.
Practice Address - Street 2:SUITE A
Practice Address - City:PATALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952
Practice Address - Country:US
Practice Address - Phone:707-216-1612
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-14
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY31800103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent