Provider Demographics
NPI:1669208930
Name:FANA, LARISSA (MA)
Entity type:Individual
Prefix:
First Name:LARISSA
Middle Name:
Last Name:FANA
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:WESTERN QUEENS CONSULTATION CENTER
Mailing Address - Street 2:44-04 QUEENS BOULEVARD 2ND FLOOR
Mailing Address - City:SUNNYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11104
Mailing Address - Country:US
Mailing Address - Phone:718-706-1663
Mailing Address - Fax:
Practice Address - Street 1:WESTERN QUEENS CONSULTATION CENTER
Practice Address - Street 2:44-04 QUEENS BOULEVARD 2ND FLOOR
Practice Address - City:SUNNYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11104
Practice Address - Country:US
Practice Address - Phone:718-706-1663
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-12
Last Update Date:2024-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015020101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health