Healthcare Provider Details

I. General information

NPI: 1467672733
Provider Name (Legal Business Name): LARISSA DAVIS BELLER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LARISSA DAVIS ROARK LPA

II. Dates (important events)

Enumeration Date: 04/27/2007
Last Update Date: 12/20/2024
Certification Date: 12/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

37 SOUTH PARK DR. STE 4
CORBIN KY
40701
US

IV. Provider business mailing address

37 SOUTH PARK DR. STE, 4
CORBIN KY
40701-0423
US

V. Phone/Fax

Practice location:
  • Phone: 859-795-1323
  • Fax:
Mailing address:
  • Phone: 859-795-1323
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number2010-53
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number259920
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: