Provider Demographics
NPI:1982010567
Name:HEISE, LARISSA (LMSW, LBA, BCBA)
Entity Type:Individual
Prefix:MS
First Name:LARISSA
Middle Name:
Last Name:HEISE
Suffix:
Gender:F
Credentials:LMSW, LBA, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24445 NORTHWESTERN HWY STE 100
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-2436
Mailing Address - Country:US
Mailing Address - Phone:248-483-7804
Mailing Address - Fax:
Practice Address - Street 1:24445 NORTHWESTERN HWY STE 100
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-2436
Practice Address - Country:US
Practice Address - Phone:248-483-7804
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-03
Last Update Date:2020-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1-16-21863103K00000X
MI68010964111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical