Provider Demographics
NPI:1720577232
Name:LERTOLA, LARISSA (BCBA)
Entity type:Individual
Prefix:
First Name:LARISSA
Middle Name:
Last Name:LERTOLA
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44225 W 12 MILE RD STE C-106
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48377-2640
Mailing Address - Country:US
Mailing Address - Phone:248-277-3005
Mailing Address - Fax:
Practice Address - Street 1:8609 W BRYN MAWR AVE STE 204
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60631-3524
Practice Address - Country:US
Practice Address - Phone:773-726-1416
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-09
Last Update Date:2025-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
156F00000X, 103K00000X
MI7401002764103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No156F00000XEye and Vision Services ProvidersTechnician/Technologist