Provider Demographics
NPI:1821493735
Name:STEWART, LARISSA GAY (LAC)
Entity Type:Individual
Prefix:MS
First Name:LARISSA
Middle Name:GAY
Last Name:STEWART
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2515 19TH AVE APT A
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31901-1374
Mailing Address - Country:US
Mailing Address - Phone:229-603-3332
Mailing Address - Fax:
Practice Address - Street 1:2008 WYNNTON RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31906-2407
Practice Address - Country:US
Practice Address - Phone:762-221-5403
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-04
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA333171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist