Provider Demographics
NPI:1750603619
Name:LARRY, LISA LAFAYE
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:LAFAYE
Last Name:LARRY
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 1:1720 E THUNDERBIRD RD
Mailing Address - Street 2:APT 2024
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85022-5770
Mailing Address - Country:US
Mailing Address - Phone:480-593-7833
Mailing Address - Fax:
Practice Address - Street 1:1720 E THUNDERBIRD RD
Practice Address - Street 2:APT 2024
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85022-5770
Practice Address - Country:US
Practice Address - Phone:480-593-7833
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-19
Last Update Date:2010-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ449603385HR2055X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child