Provider Demographics
NPI:1831628130
Name:BOODHOO, LARISSA (LCSW, CASAC)
Entity type:Individual
Prefix:MS
First Name:LARISSA
Middle Name:
Last Name:BOODHOO
Suffix:
Gender:F
Credentials:LCSW, CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2901 CARNATION AVE
Mailing Address - Street 2:
Mailing Address - City:BALDWIN
Mailing Address - State:NY
Mailing Address - Zip Code:11510-4402
Mailing Address - Country:US
Mailing Address - Phone:516-376-2906
Mailing Address - Fax:
Practice Address - Street 1:165 N VILLAGE AVE STE 119
Practice Address - Street 2:
Practice Address - City:ROCKVILLE CENTRE
Practice Address - State:NY
Practice Address - Zip Code:11570-3701
Practice Address - Country:US
Practice Address - Phone:516-376-2906
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-08
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY33740101YA0400X
NY108481104100000X
NY0979301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker