Provider Demographics
NPI:1497524870
Name:RALSTON, LARISSA
Entity Type:Individual
Prefix:
First Name:LARISSA
Middle Name:
Last Name:RALSTON
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 1:1375 US HIGHWAY 42 SE STE C
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:OH
Mailing Address - Zip Code:43140-9548
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1375 US HIGHWAY 42 SE STE C
Practice Address - Street 2:
Practice Address - City:LONDON
Practice Address - State:OH
Practice Address - Zip Code:43140-9548
Practice Address - Country:US
Practice Address - Phone:740-845-8652
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-27
Last Update Date:2023-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health