Provider Demographics
NPI:1023318078
Name:WOOLSTON, LARISSA
Entity type:Individual
Prefix:
First Name:LARISSA
Middle Name:
Last Name:WOOLSTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9832 N HAYDEN RD
Mailing Address - Street 2:STE 207
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85258-1235
Mailing Address - Country:US
Mailing Address - Phone:480-556-6797
Mailing Address - Fax:
Practice Address - Street 1:9832 N HAYDEN RD
Practice Address - Street 2:STE 207
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85258-1235
Practice Address - Country:US
Practice Address - Phone:480-556-6797
Practice Address - Fax:480-556-6670
Is Sole Proprietor?:No
Enumeration Date:2010-10-25
Last Update Date:2016-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4059688103TS0200X
AZ5973111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool