Provider Demographics
NPI:1841746419
Name:CARROLL, LARISSA RAE (ATC, LAT)
Entity Type:Individual
Prefix:
First Name:LARISSA
Middle Name:RAE
Last Name:CARROLL
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1837 OSMAN AVE
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806
Mailing Address - Country:US
Mailing Address - Phone:941-266-7041
Mailing Address - Fax:
Practice Address - Street 1:901 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-3233
Practice Address - Country:US
Practice Address - Phone:407-206-1900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL 41802255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer