Provider Demographics
NPI:1952990848
Name:LAFAVOR, LARISSA LILLIAN
Entity Type:Individual
Prefix:
First Name:LARISSA
Middle Name:LILLIAN
Last Name:LAFAVOR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LARISSA
Other - Middle Name:LILLIAN
Other - Last Name:HARRISON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1900 AMERICAN EAGLE DR
Mailing Address - Street 2:
Mailing Address - City:SLINGER
Mailing Address - State:WI
Mailing Address - Zip Code:53086-9043
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1700 W PARADISE DR
Practice Address - Street 2:
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53095-9795
Practice Address - Country:US
Practice Address - Phone:262-334-3451
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-14
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5108-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist