Provider Demographics
NPI:1982175824
Name:LARSON, MALISSA ANN
Entity type:Individual
Prefix:MISS
First Name:MALISSA
Middle Name:ANN
Last Name:LARSON
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 1:192 RICHMOND AVE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14222-2112
Mailing Address - Country:US
Mailing Address - Phone:646-823-5401
Mailing Address - Fax:
Practice Address - Street 1:192 RICHMOND AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14222-2112
Practice Address - Country:US
Practice Address - Phone:646-823-5401
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-17
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374J00000XNursing Service Related ProvidersDoula
No103TE1100XBehavioral Health & Social Service ProvidersPsychologistExercise & SportsGroup - Multi-Specialty