Healthcare Provider Details

I. General information

NPI: 1518285675
Provider Name (Legal Business Name): LARISSA D. TERRY PSY.D., BCBA-D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/12/2010
Last Update Date: 05/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

891 HOLLY HILL DR
WALNUT CREEK CA
94596-6252
US

IV. Provider business mailing address

PO BOX 1111
ALAMO CA
94507-7111
US

V. Phone/Fax

Practice location:
  • Phone: 925-933-1833
  • Fax: 800-514-6974
Mailing address:
  • Phone: 925-933-1833
  • Fax: 800-514-6974

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberBCBA-D 1-00-0003
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY19913
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: