Healthcare Provider Details

I. General information

NPI: 1205760089
Provider Name (Legal Business Name): LARISSA M NOGODA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2026
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1606 N 7TH ST
TERRE HAUTE IN
47804-2706
US

IV. Provider business mailing address

204 N 36TH ST
TERRE HAUTE IN
47803-1306
US

V. Phone/Fax

Practice location:
  • Phone: 812-238-7000
  • Fax:
Mailing address:
  • Phone: 907-317-5957
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: