Provider Demographics
NPI:1558077784
Name:ROTHER, LARISA
Entity Type:Individual
Prefix:
First Name:LARISA
Middle Name:
Last Name:ROTHER
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 1:311 BOULEVARD OF AMERICAS STE 304
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701-4788
Mailing Address - Country:US
Mailing Address - Phone:402-252-1363
Mailing Address - Fax:
Practice Address - Street 1:9802 NICHOLAS ST STE 395
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-2168
Practice Address - Country:US
Practice Address - Phone:402-252-1363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-31
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NERBT-23-255714106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician