Provider Demographics
NPI:1487044038
Name:KAVITSKY, LARISSA
Entity Type:Individual
Prefix:MISS
First Name:LARISSA
Middle Name:
Last Name:KAVITSKY
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 1:24 GALE DR
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11581-3623
Mailing Address - Country:US
Mailing Address - Phone:516-592-0582
Mailing Address - Fax:
Practice Address - Street 1:24 GALE DR
Practice Address - Street 2:
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11581-3623
Practice Address - Country:US
Practice Address - Phone:516-592-0582
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-03
Last Update Date:2015-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY509507977103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst