Provider Demographics
NPI:1427232156
Name:SIMURDAK, LARISA MARIE (BA)
Entity Type:Individual
Prefix:MS
First Name:LARISA
Middle Name:MARIE
Last Name:SIMURDAK
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4103 N 30TH ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98407-5313
Mailing Address - Country:US
Mailing Address - Phone:235-861-0860
Mailing Address - Fax:
Practice Address - Street 1:1201 S PROCTOR ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-2047
Practice Address - Country:US
Practice Address - Phone:253-396-5886
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-17
Last Update Date:2007-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor