Provider Demographics
NPI:1114404902
Name:PAULY, LARISSA TEAL (OT)
Entity type:Individual
Prefix:
First Name:LARISSA
Middle Name:TEAL
Last Name:PAULY
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:LARISSA
Other - Middle Name:
Other - Last Name:SHARSHON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:201 DEFENSE HWY STE 100
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-8902
Mailing Address - Country:US
Mailing Address - Phone:667-204-7000
Mailing Address - Fax:443-481-6515
Practice Address - Street 1:8638 VETERANS HWY FL 1
Practice Address - Street 2:
Practice Address - City:MILLERSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21108-1422
Practice Address - Country:US
Practice Address - Phone:443-481-1140
Practice Address - Fax:410-729-4526
Is Sole Proprietor?:No
Enumeration Date:2018-07-24
Last Update Date:2018-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD06826225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist