Provider Demographics
NPI:1104554898
Name:SEVERSON, LARISSA (LMHCA, CN)
Entity type:Individual
Prefix:
First Name:LARISSA
Middle Name:
Last Name:SEVERSON
Suffix:
Gender:F
Credentials:LMHCA, CN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11616 25TH AVE S
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98168-1206
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10614 BEARDSLEE BLVD STE C
Practice Address - Street 2:
Practice Address - City:BOTHELL
Practice Address - State:WA
Practice Address - Zip Code:98011-3279
Practice Address - Country:US
Practice Address - Phone:360-789-6071
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-10
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No133N00000XDietary & Nutritional Service ProvidersNutritionist