Provider Demographics
NPI:1588938252
Name:RAUN, LARISSA RENEE (PT)
Entity type:Individual
Prefix:
First Name:LARISSA
Middle Name:RENEE
Last Name:RAUN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:LARISSA
Other - Middle Name:RENEE
Other - Last Name:VAUGHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1635 CREEKSIDE DRIVE
Mailing Address - Street 2:101
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95630-3830
Mailing Address - Country:US
Mailing Address - Phone:916-983-5611
Mailing Address - Fax:916-983-5615
Practice Address - Street 1:1635 CREEKSIDE DR
Practice Address - Street 2:101
Practice Address - City:FOLSOM
Practice Address - State:CA
Practice Address - Zip Code:95630-3830
Practice Address - Country:US
Practice Address - Phone:916-983-5611
Practice Address - Fax:916-983-5615
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-28
Last Update Date:2012-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA38824225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist