Provider Demographics
NPI:1467672733
Name:ROARK, LARISSA DAVIS (LPA)
Entity Type:Individual
Prefix:MS
First Name:LARISSA
Middle Name:DAVIS
Last Name:ROARK
Suffix:
Gender:F
Credentials:LPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 423
Mailing Address - Street 2:
Mailing Address - City:BIMBLE
Mailing Address - State:KY
Mailing Address - Zip Code:40915-0423
Mailing Address - Country:US
Mailing Address - Phone:606-545-9478
Mailing Address - Fax:606-546-3903
Practice Address - Street 1:4671 SOUTH CUMBERLAND GAP PARKWAY
Practice Address - Street 2:
Practice Address - City:BIMBLE
Practice Address - State:KY
Practice Address - Zip Code:40915-0423
Practice Address - Country:US
Practice Address - Phone:606-545-9478
Practice Address - Fax:606-546-3903
Is Sole Proprietor?:No
Enumeration Date:2007-04-27
Last Update Date:2011-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
KY2010-53103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health