Provider Demographics
NPI:1912488313
Name:HINE, LARISSA (OTR/L)
Entity Type:Individual
Prefix:
First Name:LARISSA
Middle Name:
Last Name:HINE
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:383 HOLBROOK BAY CMNS APT 17
Mailing Address - Street 2:
Mailing Address - City:NEWPORT CENTER
Mailing Address - State:VT
Mailing Address - Zip Code:05857-9315
Mailing Address - Country:US
Mailing Address - Phone:508-521-3039
Mailing Address - Fax:
Practice Address - Street 1:189 PROUTY DR
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:VT
Practice Address - Zip Code:05855-9820
Practice Address - Country:US
Practice Address - Phone:802-334-7331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-23
Last Update Date:2018-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10543225X00000X
VT0112027225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist