Provider Demographics
NPI:1104673359
Name:LARSEN, ALYSIA RO
Entity type:Individual
Prefix:
First Name:ALYSIA
Middle Name:RO
Last Name:LARSEN
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 1:17977 SW ARBORCREST CT
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97003-4407
Mailing Address - Country:US
Mailing Address - Phone:503-421-6065
Mailing Address - Fax:
Practice Address - Street 1:17977 SW ARBORCREST CT
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97003-4407
Practice Address - Country:US
Practice Address - Phone:503-421-6065
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-06
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician