Provider Demographics
NPI:1841641586
Name:FRAVEL, LARISSA
Entity type:Individual
Prefix:
First Name:LARISSA
Middle Name:
Last Name:FRAVEL
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1620 S LAWE ST
Mailing Address - Street 2:STE 1
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54915-2419
Mailing Address - Country:US
Mailing Address - Phone:920-284-9676
Mailing Address - Fax:920-481-3121
Practice Address - Street 1:1620 S LAWE ST STE 1
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54915-2419
Practice Address - Country:US
Practice Address - Phone:920-915-0102
Practice Address - Fax:920-481-3121
Is Sole Proprietor?:No
Enumeration Date:2016-06-23
Last Update Date:2025-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5984-125101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health