Provider Demographics
NPI:1518597814
Name:PHILLIPS, LARRESA KEYONNA (MS,CCC-SLP)
Entity Type:Individual
Prefix:
First Name:LARRESA
Middle Name:KEYONNA
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:MS,CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2417 HIGHLAND DR
Mailing Address - Street 2:
Mailing Address - City:VIOLET
Mailing Address - State:LA
Mailing Address - Zip Code:70092-2962
Mailing Address - Country:US
Mailing Address - Phone:281-662-5107
Mailing Address - Fax:
Practice Address - Street 1:2417 HIGHLAND DR
Practice Address - Street 2:
Practice Address - City:VIOLET
Practice Address - State:LA
Practice Address - Zip Code:70092-2962
Practice Address - Country:US
Practice Address - Phone:281-662-5107
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-25
Last Update Date:2020-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA8129235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist