Provider Demographics
NPI:1669806246
Name:ARCHULETA, LARISSA FERNE (LCSW)
Entity type:Individual
Prefix:
First Name:LARISSA
Middle Name:FERNE
Last Name:ARCHULETA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3862 S 2915 W
Mailing Address - Street 2:
Mailing Address - City:WEST HAVEN
Mailing Address - State:UT
Mailing Address - Zip Code:84401-9865
Mailing Address - Country:US
Mailing Address - Phone:801-678-3291
Mailing Address - Fax:
Practice Address - Street 1:962 CHAMBERS ST STE 11
Practice Address - Street 2:
Practice Address - City:SOUTH OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-5092
Practice Address - Country:US
Practice Address - Phone:801-625-3700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-30
Last Update Date:2023-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7756352-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT260022408OtherRAILROAD MEDICARE
UT876000308007Medicaid
UT000055266Medicare PIN