Provider Demographics
NPI:1427300870
Name:SORRELLS, LARISSA
Entity type:Individual
Prefix:
First Name:LARISSA
Middle Name:
Last Name:SORRELLS
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 1:21 NORTH DR
Mailing Address - Street 2:
Mailing Address - City:BEARDSTOWN
Mailing Address - State:IL
Mailing Address - Zip Code:62618-4400
Mailing Address - Country:US
Mailing Address - Phone:217-248-5795
Mailing Address - Fax:
Practice Address - Street 1:400 E 4TH ST
Practice Address - Street 2:
Practice Address - City:BEARDSTOWN
Practice Address - State:IL
Practice Address - Zip Code:62618-1307
Practice Address - Country:US
Practice Address - Phone:217-248-5795
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-10
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070019416225100000X
IL056009166225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist