Provider Demographics
NPI:1790463859
Name:MYERS, LARISSA SOPHIE
Entity Type:Individual
Prefix:
First Name:LARISSA
Middle Name:SOPHIE
Last Name:MYERS
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 1:1707 IVYWOOD DR
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48103-4523
Mailing Address - Country:US
Mailing Address - Phone:832-314-1408
Mailing Address - Fax:
Practice Address - Street 1:17320 W 12 MILE RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-2100
Practice Address - Country:US
Practice Address - Phone:248-727-3456
Practice Address - Fax:248-557-4697
Is Sole Proprietor?:No
Enumeration Date:2023-07-10
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical