Provider Demographics
NPI:1528396165
Name:WING, LARISA G
Entity Type:Individual
Prefix:
First Name:LARISA
Middle Name:G
Last Name:WING
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 1:33 KENNEDY MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:WATERVILLE
Mailing Address - State:ME
Mailing Address - Zip Code:04901-5128
Mailing Address - Country:US
Mailing Address - Phone:207-626-3497
Mailing Address - Fax:
Practice Address - Street 1:18 RIGA ROAD
Practice Address - Street 2:
Practice Address - City:CHINA
Practice Address - State:ME
Practice Address - Zip Code:04358
Practice Address - Country:US
Practice Address - Phone:207-557-2545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-19
Last Update Date:2020-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MESAS17632355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant