Provider Demographics
NPI:1417922725
Name:MEAD-WESCOTT, LARISSA ARAXE (PHD)
Entity Type:Individual
Prefix:
First Name:LARISSA
Middle Name:ARAXE
Last Name:MEAD-WESCOTT
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:LARISSA
Other - Middle Name:ARAXE
Other - Last Name:MEAD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:277 STATE ST
Mailing Address - Street 2:SUITE 2A
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-5439
Mailing Address - Country:US
Mailing Address - Phone:207-990-2580
Mailing Address - Fax:207-990-1930
Practice Address - Street 1:277 STATE ST
Practice Address - Street 2:SUITE 2A
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-5439
Practice Address - Country:US
Practice Address - Phone:207-990-2580
Practice Address - Fax:207-990-1930
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2010-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPS960103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
036895OtherANTHEM
3069401OtherAETNA
ME330640099Medicaid
3069401OtherAETNA