Provider Demographics
NPI:1801595921
Name:SLISENKO, LARISA PAVLOVNA (LMT)
Entity type:Individual
Prefix:
First Name:LARISA
Middle Name:PAVLOVNA
Last Name:SLISENKO
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:513 W 14TH AVE
Mailing Address - Street 2:
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83854-7210
Mailing Address - Country:US
Mailing Address - Phone:509-608-9987
Mailing Address - Fax:
Practice Address - Street 1:18507 E APPLEWAY AVE STE 206
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99016-5172
Practice Address - Country:US
Practice Address - Phone:509-828-0181
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-27
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA61115965225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist