Provider Demographics
NPI:1942579214
Name:FREMONT, LARISSA MARIE (MS)
Entity Type:Individual
Prefix:MRS
First Name:LARISSA
Middle Name:MARIE
Last Name:FREMONT
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 PLEASANT AVE
Mailing Address - Street 2:
Mailing Address - City:SCHAGHTICOKE
Mailing Address - State:NY
Mailing Address - Zip Code:12154-3908
Mailing Address - Country:US
Mailing Address - Phone:518-753-4458
Mailing Address - Fax:
Practice Address - Street 1:2 PLEASANT AVE
Practice Address - Street 2:
Practice Address - City:SCHAGHTICOKE
Practice Address - State:NY
Practice Address - Zip Code:12154-3908
Practice Address - Country:US
Practice Address - Phone:518-753-4458
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-15
Last Update Date:2013-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018062-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1063560274Medicaid