Provider Demographics
NPI:1598099590
Name:BERMEJO, LARISA DAGNE (MA)
Entity Type:Individual
Prefix:PROF
First Name:LARISA
Middle Name:DAGNE
Last Name:BERMEJO
Suffix:
Gender:F
Credentials:MA
Other - Prefix:MS
Other - First Name:LARISA
Other - Middle Name:DAGNE
Other - Last Name:BERMEJO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:85 GRAND CANAL DR STE 310
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33144-2570
Mailing Address - Country:US
Mailing Address - Phone:305-263-8228
Mailing Address - Fax:305-263-8236
Practice Address - Street 1:85 GRAND CANAL DR STE 310
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33144-2570
Practice Address - Country:US
Practice Address - Phone:305-263-8228
Practice Address - Fax:305-263-8236
Is Sole Proprietor?:No
Enumeration Date:2009-09-23
Last Update Date:2009-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH9342111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor