Provider Demographics
NPI:1205610961
Name:LARREA, MARIEMILIA (PSYD)
Entity type:Individual
Prefix:DR
First Name:MARIEMILIA
Middle Name:
Last Name:LARREA
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3699 LENOX RD NE APT 556
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30305-3881
Mailing Address - Country:US
Mailing Address - Phone:239-603-4365
Mailing Address - Fax:
Practice Address - Street 1:32 LENOX POINTE NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30324-5699
Practice Address - Country:US
Practice Address - Phone:404-590-0398
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-23
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL390200000X
GA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program