Provider Demographics
NPI:1629794136
Name:KIRBY, LARISSA L (CMI)
Entity Type:Individual
Prefix:
First Name:LARISSA
Middle Name:L
Last Name:KIRBY
Suffix:
Gender:F
Credentials:CMI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 MEDICAL PKWY
Mailing Address - Street 2:
Mailing Address - City:CLAREMORE
Mailing Address - State:OK
Mailing Address - Zip Code:74017-1088
Mailing Address - Country:US
Mailing Address - Phone:918-342-0770
Mailing Address - Fax:918-342-0087
Practice Address - Street 1:3100 MEDICAL PKWY
Practice Address - Street 2:
Practice Address - City:CLAREMORE
Practice Address - State:OK
Practice Address - Zip Code:74017-1088
Practice Address - Country:US
Practice Address - Phone:918-342-0770
Practice Address - Fax:918-342-0087
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-17
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK318595171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator