Provider Demographics
NPI:1275863276
Name:OLIVEIRA, LARISSA DIAS (DPT)
Entity Type:Individual
Prefix:MRS
First Name:LARISSA
Middle Name:DIAS
Last Name:OLIVEIRA
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:MISS
Other - First Name:LARISSA
Other - Middle Name:TAVARES
Other - Last Name:DIAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:8862 KEPHART LN
Mailing Address - Street 2:UNIT 3
Mailing Address - City:BERRIEN SPRINGS
Mailing Address - State:MI
Mailing Address - Zip Code:49103-1048
Mailing Address - Country:US
Mailing Address - Phone:951-892-8900
Mailing Address - Fax:
Practice Address - Street 1:8862 KEPHART LN
Practice Address - Street 2:UNIT 3
Practice Address - City:BERRIEN SPRINGS
Practice Address - State:MI
Practice Address - Zip Code:49103-1048
Practice Address - Country:US
Practice Address - Phone:951-892-8900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-14
Last Update Date:2017-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1256971225100000X
MI5501015387225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
8FAU94OtherBLUE CROSS BLUE SHIELD
TX350048001Medicaid