Provider Demographics
NPI:1477986313
Name:TRELOAR, LARISSA LEE (SLP)
Entity Type:Individual
Prefix:
First Name:LARISSA
Middle Name:LEE
Last Name:TRELOAR
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:LARISSA
Other - Middle Name:LEE
Other - Last Name:CHRISTENSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1810 4TH ST SW STE 103A
Mailing Address - Street 2:
Mailing Address - City:WAVERLY
Mailing Address - State:IA
Mailing Address - Zip Code:50677-4389
Mailing Address - Country:US
Mailing Address - Phone:319-352-1234
Mailing Address - Fax:319-352-4655
Practice Address - Street 1:1810 4TH ST SW STE 103A
Practice Address - Street 2:
Practice Address - City:WAVERLY
Practice Address - State:IA
Practice Address - Zip Code:50677-4389
Practice Address - Country:US
Practice Address - Phone:319-352-1234
Practice Address - Fax:319-352-4655
Is Sole Proprietor?:No
Enumeration Date:2013-08-14
Last Update Date:2013-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA002347235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0665992Medicaid
IA166599Medicare Oscar/Certification