Provider Demographics
NPI:1386920189
Name:WOLFORD, LARISSA ROSE (MA, LMFT)
Entity type:Individual
Prefix:MS
First Name:LARISSA
Middle Name:ROSE
Last Name:WOLFORD
Suffix:
Gender:F
Credentials:MA, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1683 NOVATO BLVD STE 8
Mailing Address - Street 2:
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94947-3284
Mailing Address - Country:US
Mailing Address - Phone:415-609-4077
Mailing Address - Fax:
Practice Address - Street 1:1683 NOVATO BLVD STE 8
Practice Address - Street 2:
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94947-3284
Practice Address - Country:US
Practice Address - Phone:415-609-4077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-25
Last Update Date:2016-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA47710106H00000X
CA1065101YP2500X
CA140082874101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA13678958OtherCAQH