Provider Demographics
NPI:1215435524
Name:TENOH, LARISSA T
Entity type:Individual
Prefix:
First Name:LARISSA
Middle Name:T
Last Name:TENOH
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 1:6419 JODIE ST
Mailing Address - Street 2:
Mailing Address - City:NEW CARROLLTON
Mailing Address - State:MD
Mailing Address - Zip Code:20784-3633
Mailing Address - Country:US
Mailing Address - Phone:240-636-2192
Mailing Address - Fax:
Practice Address - Street 1:4645 NANNIE HELEN BURROUGHS AVE NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20019-3622
Practice Address - Country:US
Practice Address - Phone:202-733-4904
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-01
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X, 171M00000X
DCHHA13473374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172V00000XOther Service ProvidersCommunity Health Worker
No374U00000XNursing Service Related ProvidersHome Health Aide