Healthcare Provider Details

I. General information

NPI: 1720577232
Provider Name (Legal Business Name): LARISSA LERTOLA BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2018
Last Update Date: 04/07/2025
Certification Date: 04/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8609 W BRYN MAWR AVE STE 204
CHICAGO IL
60631-3524
US

IV. Provider business mailing address

44225 W 12 MILE RD STE C-106
NOVI MI
48377-2640
US

V. Phone/Fax

Practice location:
  • Phone: 773-726-1416
  • Fax:
Mailing address:
  • Phone: 248-277-3005
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code156F00000X
TaxonomyTechnician/Technologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number7401002764
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: