Provider Demographics
NPI:1770253965
Name:MOODY ALLSOP, LARISE
Entity Type:Individual
Prefix:
First Name:LARISE
Middle Name:
Last Name:MOODY ALLSOP
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 1:3393 RALEIGH DR
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33884-5219
Mailing Address - Country:US
Mailing Address - Phone:863-229-5541
Mailing Address - Fax:
Practice Address - Street 1:2980 PARK POND WAY
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-7660
Practice Address - Country:US
Practice Address - Phone:407-930-4711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-17
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health