Provider Demographics
NPI:1457829616
Name:STREET, LARISSA ANN
Entity Type:Individual
Prefix:
First Name:LARISSA
Middle Name:ANN
Last Name:STREET
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26601 QUANTICO CREEK RD
Mailing Address - Street 2:
Mailing Address - City:HEBRON
Mailing Address - State:MD
Mailing Address - Zip Code:21830-2183
Mailing Address - Country:US
Mailing Address - Phone:845-389-3942
Mailing Address - Fax:
Practice Address - Street 1:700 GLASGOW ST
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MD
Practice Address - Zip Code:21613-1738
Practice Address - Country:US
Practice Address - Phone:410-228-4747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-06
Last Update Date:2018-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD06716235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist