Provider Demographics
NPI:1942352034
Name:GOLLOUB, LARISSA ELLEN (LCSW-R)
Entity Type:Individual
Prefix:MS
First Name:LARISSA
Middle Name:ELLEN
Last Name:GOLLOUB
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Gender:F
Credentials:LCSW-R
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Other - First Name:
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Mailing Address - Street 1:11115 75TH AVE
Mailing Address - Street 2:APT. 5M
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-6327
Mailing Address - Country:US
Mailing Address - Phone:718-890-8100
Mailing Address - Fax:718-495-8298
Practice Address - Street 1:2581 ATLANTIC AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11207-2412
Practice Address - Country:US
Practice Address - Phone:718-890-8100
Practice Address - Fax:718-495-8298
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NYR050308-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical