Provider Demographics
NPI:1831796176
Name:GRAY, LARISSA
Entity type:Individual
Prefix:
First Name:LARISSA
Middle Name:
Last Name:GRAY
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 1:54TH TERRACE AVE
Mailing Address - Street 2:APARTMENT D1710
Mailing Address - City:ST. PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33712
Mailing Address - Country:US
Mailing Address - Phone:386-956-3203
Mailing Address - Fax:
Practice Address - Street 1:12505 STARKEY RD STE K
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33773-2617
Practice Address - Country:US
Practice Address - Phone:727-280-6643
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-08
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician