Provider Demographics
NPI:1063757409
Name:CABRAL, LARISSA SUE
Entity type:Individual
Prefix:
First Name:LARISSA
Middle Name:SUE
Last Name:CABRAL
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 1:30 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06095-2922
Mailing Address - Country:US
Mailing Address - Phone:860-246-7999
Mailing Address - Fax:860-688-0004
Practice Address - Street 1:41 MECHANIC ST
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06095-2545
Practice Address - Country:US
Practice Address - Phone:860-246-7999
Practice Address - Fax:860-688-0004
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-11
Last Update Date:2012-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001421106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist