Provider Demographics
NPI:1144877168
Name:VANSICE, LARISSA MICHELLE
Entity type:Individual
Prefix:
First Name:LARISSA
Middle Name:MICHELLE
Last Name:VANSICE
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 1:711 QUEEN ST
Mailing Address - Street 2:
Mailing Address - City:OWOSSO
Mailing Address - State:MI
Mailing Address - Zip Code:48867-2459
Mailing Address - Country:US
Mailing Address - Phone:989-494-3665
Mailing Address - Fax:
Practice Address - Street 1:5980 RADIO STATION RD
Practice Address - Street 2:
Practice Address - City:LA PLATA
Practice Address - State:MD
Practice Address - Zip Code:20646-3337
Practice Address - Country:US
Practice Address - Phone:301-932-6610
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-23
Last Update Date:2019-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist