Provider Demographics
NPI:1699015354
Name:REYNOLDS, LARISSA KERN (PHD, BCBA-D)
Entity Type:Individual
Prefix:DR
First Name:LARISSA
Middle Name:KERN
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:PHD, BCBA-D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14607 NADINE DRIVE
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20853
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8615 EAST VILLAGE AVENUE
Practice Address - Street 2:
Practice Address - City:MONTGOMERY VILLAGE
Practice Address - State:MD
Practice Address - Zip Code:20886
Practice Address - Country:US
Practice Address - Phone:240-912-3677
Practice Address - Fax:240-912-2288
Is Sole Proprietor?:No
Enumeration Date:2013-02-18
Last Update Date:2013-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
MD03420103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst