Provider Demographics
NPI:1538478714
Name:HUMISTON, LARISSA K (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:LARISSA
Middle Name:K
Last Name:HUMISTON
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:456 GALLBERRY ST
Mailing Address - Street 2:
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32714-2499
Mailing Address - Country:US
Mailing Address - Phone:407-415-1175
Mailing Address - Fax:
Practice Address - Street 1:1414 GAY RD
Practice Address - Street 2:SUITE 205
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789-2928
Practice Address - Country:US
Practice Address - Phone:407-415-1175
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-05
Last Update Date:2013-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW95761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical