Provider Demographics
NPI:1487242210
Name:VAN WIE, LARISSA (RBT)
Entity type:Individual
Prefix:MRS
First Name:LARISSA
Middle Name:
Last Name:VAN WIE
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15116 N COTTON LN
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85388-9618
Mailing Address - Country:US
Mailing Address - Phone:623-322-8250
Mailing Address - Fax:602-485-8859
Practice Address - Street 1:15116 N COTTON LN
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85388-9618
Practice Address - Country:US
Practice Address - Phone:623-322-8250
Practice Address - Fax:602-485-8859
Is Sole Proprietor?:No
Enumeration Date:2021-01-07
Last Update Date:2024-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRBT-21-150641106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician