MEDICARE: LARISSA MARIE SPOHN MS, LPCA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor	A14996	NC

General Provider Information

NPI Number	:	1508410564
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LARISSA MARIE SPOHN MS, LPCA

Provider Business Mailing Address
First Line	:	3361 WILLS GROVE LN APT 305
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27615-8070
Country	:	US
Telephone Number	:	610-730-2723
Fax Number	:

Provider Business Practice Location Address
First Line	:	6608 SIX FORKS RD STE 204
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27615-6522
Country	:	US
Telephone Number	:	919-514-3566
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/29/2019
Last Update Date	:	07/29/2019

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