Provider Demographics
NPI:1669858882
Name:HABING, LARISSA (RD)
Entity Type:Individual
Prefix:
First Name:LARISSA
Middle Name:
Last Name:HABING
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:67 EXECUTIVE DR
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:IL
Mailing Address - Zip Code:62249-1286
Mailing Address - Country:US
Mailing Address - Phone:618-654-4701
Mailing Address - Fax:618-654-4739
Practice Address - Street 1:67 EXECUTIVE DR
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:IL
Practice Address - Zip Code:62249-1286
Practice Address - Country:US
Practice Address - Phone:618-654-4701
Practice Address - Fax:618-654-4739
Is Sole Proprietor?:No
Enumeration Date:2015-08-11
Last Update Date:2015-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.002934133V00000X
MO2005012528133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered