Provider Demographics
NPI:1205534831
Name:LARRISON, LONNIE JAMES (CO 61378037)
Entity type:Individual
Prefix:
First Name:LONNIE
Middle Name:JAMES
Last Name:LARRISON
Suffix:
Gender:M
Credentials:CO 61378037
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 S 3RD ST
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98901-2875
Mailing Address - Country:US
Mailing Address - Phone:509-248-1800
Mailing Address - Fax:
Practice Address - Street 1:120 SOUTH 3RD STREET
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98901-2875
Practice Address - Country:US
Practice Address - Phone:509-248-1800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-22
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 175T00000X
WACO61378037101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA910755984Medicaid
WA2235389Medicaid