Healthcare Provider Details

I. General information

NPI: 1659828606
Provider Name (Legal Business Name): LARISSA GELERIS M.S., OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2016
Last Update Date: 09/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 MT DIABLO BLVD SUITE 200
LAFAYETTE CA
94549-3956
US

IV. Provider business mailing address

1113 ROXIE LN
WALNUT CREEK CA
94597-1806
US

V. Phone/Fax

Practice location:
  • Phone: 925-954-4546
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number16480
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: