Provider Demographics
NPI:1699501148
Name:ROSS, LARISSA (PSYS)
Entity type:Individual
Prefix:
First Name:LARISSA
Middle Name:
Last Name:ROSS
Suffix:
Gender:F
Credentials:PSYS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:998 GRIZZLY CUB DR
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:IN
Mailing Address - Zip Code:46131-1375
Mailing Address - Country:US
Mailing Address - Phone:317-346-8755
Mailing Address - Fax:
Practice Address - Street 1:101 IN-44
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:IN
Practice Address - Zip Code:46131
Practice Address - Country:US
Practice Address - Phone:317-346-8755
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-11
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1543648103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool