Provider Demographics
NPI:1821545203
Name:DALLAS, LARNESSA (CPRP, MHP,AAS)
Entity Type:Individual
Prefix:
First Name:LARNESSA
Middle Name:
Last Name:DALLAS
Suffix:
Gender:F
Credentials:CPRP, MHP,AAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:734 HICKORY LIMB CIR
Mailing Address - Street 2:
Mailing Address - City:BEL AIR
Mailing Address - State:MD
Mailing Address - Zip Code:21014-1898
Mailing Address - Country:US
Mailing Address - Phone:302-331-4551
Mailing Address - Fax:443-371-7667
Practice Address - Street 1:734 HICKORY LIMB CIR
Practice Address - Street 2:
Practice Address - City:BEL AIR
Practice Address - State:MD
Practice Address - Zip Code:21014-1898
Practice Address - Country:US
Practice Address - Phone:302-331-4551
Practice Address - Fax:443-371-7667
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-02
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD47-1223781225C00000X, 101YM0800X, 171M00000X, 225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD47-1223781OtherIRS