Provider Demographics
NPI:1518285675
Name:TERRY, LARISSA D (PSYD, BCBA-D)
Entity Type:Individual
Prefix:DR
First Name:LARISSA
Middle Name:D
Last Name:TERRY
Suffix:
Gender:F
Credentials:PSYD, BCBA-D
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 1111
Mailing Address - Street 2:
Mailing Address - City:ALAMO
Mailing Address - State:CA
Mailing Address - Zip Code:94507-7111
Mailing Address - Country:US
Mailing Address - Phone:925-933-1833
Mailing Address - Fax:800-514-6974
Practice Address - Street 1:891 HOLLY HILL DR
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94596-6252
Practice Address - Country:US
Practice Address - Phone:925-933-1833
Practice Address - Fax:800-514-6974
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-12
Last Update Date:2010-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
BCBA-D 1-00-0003103K00000X
CAPSY19913103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst