Provider Demographics
NPI:1962000919
Name:MCDONOUGH, LARISSA (BCBA)
Entity Type:Individual
Prefix:
First Name:LARISSA
Middle Name:
Last Name:MCDONOUGH
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2236 FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:VT
Mailing Address - Zip Code:05733-9782
Mailing Address - Country:US
Mailing Address - Phone:802-775-8224
Mailing Address - Fax:802-747-7699
Practice Address - Street 1:78 S MAIN ST
Practice Address - Street 2:
Practice Address - City:RUTLAND
Practice Address - State:VT
Practice Address - Zip Code:05701-4594
Practice Address - Country:US
Practice Address - Phone:802-775-8224
Practice Address - Fax:802-747-7699
Is Sole Proprietor?:No
Enumeration Date:2020-10-13
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT146.0134161103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst