Provider Demographics
NPI:1629688437
Name:EDWARDS, LARISSA-JAYNE (PHD)
Entity Type:Individual
Prefix:
First Name:LARISSA-JAYNE
Middle Name:
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10000 BAY PINES BLVD
Mailing Address - Street 2:
Mailing Address - City:BAY PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33744-8200
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10000 BAY PINES BLVD
Practice Address - Street 2:
Practice Address - City:BAY PINES
Practice Address - State:FL
Practice Address - Zip Code:33744-8200
Practice Address - Country:US
Practice Address - Phone:716-867-5846
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-06
Last Update Date:2021-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2177103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling