Provider Demographics
NPI:1790243756
Name:DIDRIKSEN, LARISSA MARIE (LCSW)
Entity Type:Individual
Prefix:
First Name:LARISSA
Middle Name:MARIE
Last Name:DIDRIKSEN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W1037 ARALIA RD
Mailing Address - Street 2:
Mailing Address - City:GENOA CITY
Mailing Address - State:WI
Mailing Address - Zip Code:53128-1574
Mailing Address - Country:US
Mailing Address - Phone:262-208-0078
Mailing Address - Fax:
Practice Address - Street 1:9716 US HIGHWAY 12
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:IL
Practice Address - Zip Code:60071-9253
Practice Address - Country:US
Practice Address - Phone:815-581-8131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-08
Last Update Date:2019-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490102211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical