Healthcare Provider Details

I. General information

NPI: 1184958829
Provider Name (Legal Business Name): LARISSA NADYA RZEMIENSKI M.C., L.P.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2009
Last Update Date: 09/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1444 E SOUTH FORK DR
PHOENIX AZ
85048-6252
US

IV. Provider business mailing address

1444 E. SOUTH FORK DRIVE
PHOENIX AZ
85048
US

V. Phone/Fax

Practice location:
  • Phone: 602-361-0225
  • Fax:
Mailing address:
  • Phone: 602-361-0225
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLPC - 11014
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: