Provider Demographics
NPI:1215672837
Name:CZERNOWSKI, LARISA IVANA
Entity type:Individual
Prefix:
First Name:LARISA
Middle Name:IVANA
Last Name:CZERNOWSKI
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 1:1455 SE MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-4213
Mailing Address - Country:US
Mailing Address - Phone:541-670-4722
Mailing Address - Fax:
Practice Address - Street 1:2575 NW KLINE ST
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-8827
Practice Address - Country:US
Practice Address - Phone:541-673-3504
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-28
Last Update Date:2022-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORT-22-1577101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)