Healthcare Provider Details

I. General information

NPI: 1245149038
Provider Name (Legal Business Name): LARISSA WISE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2026
Last Update Date: 09/05/2026
Certification Date: 09/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

729 REMINGTON ST
FORT COLLINS CO
80524-3332
US

IV. Provider business mailing address

7133 WOODROW DR
FORT COLLINS CO
80525-7091
US

V. Phone/Fax

Practice location:
  • Phone: 970-484-8427
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: