Provider Demographics
NPI:1710654694
Name:CLIFFORD, LARISSA
Entity Type:Individual
Prefix:
First Name:LARISSA
Middle Name:
Last Name:CLIFFORD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 COURT ST
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:OH
Mailing Address - Zip Code:45662-3932
Mailing Address - Country:US
Mailing Address - Phone:740-354-6685
Mailing Address - Fax:740-876-4005
Practice Address - Street 1:411 COURT ST
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:OH
Practice Address - Zip Code:45662-3932
Practice Address - Country:US
Practice Address - Phone:740-354-6685
Practice Address - Fax:740-876-4005
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-27
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant