Provider Demographics
NPI:1407748494
Name:LARSON, ELISSA (NBC-HWC)
Entity type:Individual
Prefix:
First Name:ELISSA
Middle Name:
Last Name:LARSON
Suffix:
Gender:F
Credentials:NBC-HWC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:156 SHARON DR
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30115-9622
Mailing Address - Country:US
Mailing Address - Phone:770-843-8192
Mailing Address - Fax:
Practice Address - Street 1:156 SHARON DR
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30115-9622
Practice Address - Country:US
Practice Address - Phone:770-843-8192
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-16
Last Update Date:2025-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAA-3991527171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach