Provider Demographics
NPI:1780299180
Name:NIESSEN, LARISSA (MS CCC-SLP/L)
Entity type:Individual
Prefix:
First Name:LARISSA
Middle Name:
Last Name:NIESSEN
Suffix:
Gender:F
Credentials:MS CCC-SLP/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 S BREA BLVD UNIT 16
Mailing Address - Street 2:
Mailing Address - City:BREA
Mailing Address - State:CA
Mailing Address - Zip Code:92821-6810
Mailing Address - Country:US
Mailing Address - Phone:805-705-5088
Mailing Address - Fax:
Practice Address - Street 1:1401 W VALENCIA DR
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92833-3998
Practice Address - Country:US
Practice Address - Phone:714-447-7745
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-11
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23092235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist