Provider Demographics
NPI:1669888921
Name:LARISH, AMY
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:LARISH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1002 POPES CREEK CIR
Mailing Address - Street 2:
Mailing Address - City:GRAYSLAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60030-1143
Mailing Address - Country:US
Mailing Address - Phone:724-372-5215
Mailing Address - Fax:888-990-2910
Practice Address - Street 1:1002 POPES CREEK CIR
Practice Address - Street 2:
Practice Address - City:GRAYSLAKE
Practice Address - State:IL
Practice Address - Zip Code:60030-1143
Practice Address - Country:US
Practice Address - Phone:724-372-5215
Practice Address - Fax:888-990-2910
Is Sole Proprietor?:No
Enumeration Date:2014-07-08
Last Update Date:2015-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070012702225100000X
WI12905225100000X
IA004293225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist