Provider Demographics
NPI:1962976647
Name:LARISSA HUMISTON, LCSW
Entity type:Organization
Organization Name:LARISSA HUMISTON, LCSW
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LARISSA
Authorized Official - Middle Name:K
Authorized Official - Last Name:HUMISTON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:407-415-1175
Mailing Address - Street 1:1414 GAY RD STE 205
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32789-2928
Mailing Address - Country:US
Mailing Address - Phone:407-415-1175
Mailing Address - Fax:
Practice Address - Street 1:1414 GAY RD STE 205
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789-2928
Practice Address - Country:US
Practice Address - Phone:407-415-1175
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-16
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1538478714OtherINSURANCE PANELS