Provider Demographics
NPI:1972942795
Name:HEAP, LARISSA ANTHEA (MSW)
Entity Type:Individual
Prefix:MS
First Name:LARISSA
Middle Name:ANTHEA
Last Name:HEAP
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1410 S TELEGRAPH RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48302-0046
Mailing Address - Country:US
Mailing Address - Phone:248-975-5639
Mailing Address - Fax:
Practice Address - Street 1:51111 WOODWARD AVE
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48342-5036
Practice Address - Country:US
Practice Address - Phone:248-975-5639
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-14
Last Update Date:2013-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801086996104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker