Provider Demographics
NPI:1508410564
Name:SPOHN, LARISSA MARIE (MS, LPCA)
Entity Type:Individual
Prefix:
First Name:LARISSA
Middle Name:MARIE
Last Name:SPOHN
Suffix:
Gender:F
Credentials:MS, LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3361 WILLS GROVE LN APT 305
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27615-8070
Mailing Address - Country:US
Mailing Address - Phone:610-730-2723
Mailing Address - Fax:
Practice Address - Street 1:6608 SIX FORKS RD STE 204
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27615-6522
Practice Address - Country:US
Practice Address - Phone:919-514-3566
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-29
Last Update Date:2019-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA14996101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor