Provider Demographics
NPI:1801224621
Name:GONZALEZ, LARISSA ABIGAIL (SLP - INTERN)
Entity Type:Individual
Prefix:
First Name:LARISSA
Middle Name:ABIGAIL
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:SLP - INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:815 CALLE FRESNAL
Mailing Address - Street 2:
Mailing Address - City:BROWNSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78521-4194
Mailing Address - Country:US
Mailing Address - Phone:956-545-7959
Mailing Address - Fax:
Practice Address - Street 1:729 N 77 SUNSHINESTRIP
Practice Address - Street 2:
Practice Address - City:HARLINGEN
Practice Address - State:TX
Practice Address - Zip Code:78550-8847
Practice Address - Country:US
Practice Address - Phone:956-421-4667
Practice Address - Fax:956-421-2016
Is Sole Proprietor?:No
Enumeration Date:2013-10-15
Last Update Date:2014-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX109626235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX021738201Medicaid
TX456838Medicare Oscar/Certification