Provider Demographics
NPI:1366715591
Name:PALMER, LARISA M (PSYD)
Entity type:Individual
Prefix:DR
First Name:LARISA
Middle Name:M
Last Name:PALMER
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 S FEDERAL HWY STE 302
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33020-6811
Mailing Address - Country:US
Mailing Address - Phone:954-925-3191
Mailing Address - Fax:954-925-3193
Practice Address - Street 1:210 S FEDERAL HWY STE 302
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33020-6811
Practice Address - Country:US
Practice Address - Phone:954-925-3191
Practice Address - Fax:954-925-3193
Is Sole Proprietor?:No
Enumeration Date:2012-02-19
Last Update Date:2012-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY7753103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical