Provider Demographics
NPI:1770861643
Name:LARAIA, MICHELLE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:LARAIA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:MALLARDI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSED
Mailing Address - Street 1:2653 STONY ST
Mailing Address - Street 2:
Mailing Address - City:MOHEGAN LAKE
Mailing Address - State:NY
Mailing Address - Zip Code:10547-2009
Mailing Address - Country:US
Mailing Address - Phone:914-245-9206
Mailing Address - Fax:914-245-9209
Practice Address - Street 1:2653 STONY ST
Practice Address - Street 2:
Practice Address - City:MOHEGAN LAKE
Practice Address - State:NY
Practice Address - Zip Code:10547-2009
Practice Address - Country:US
Practice Address - Phone:914-245-9206
Practice Address - Fax:914-245-9209
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-26
Last Update Date:2011-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst