Provider Demographics
NPI:1124281787
Name:SWAN, LARISSA P (MS,OTR/L)
Entity type:Individual
Prefix:
First Name:LARISSA
Middle Name:P
Last Name:SWAN
Suffix:
Gender:F
Credentials:MS,OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6356 DEERFIELD DR
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143-9151
Mailing Address - Country:US
Mailing Address - Phone:317-859-2196
Mailing Address - Fax:
Practice Address - Street 1:377 WESTRIDGE BLVD
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46142-2137
Practice Address - Country:US
Practice Address - Phone:317-888-4948
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-03
Last Update Date:2008-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31002041A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist