Healthcare Provider Details

I. General information

NPI: 1821545203
Provider Name (Legal Business Name): LARNESSA DALLAS CPRP, MHP,AAS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2016
Last Update Date: 09/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

734 HICKORY LIMB CIR
BEL AIR MD
21014-1898
US

IV. Provider business mailing address

734 HICKORY LIMB CIR
BEL AIR MD
21014-1898
US

V. Phone/Fax

Practice location:
  • Phone: 302-331-4551
  • Fax: 443-371-7667
Mailing address:
  • Phone: 302-331-4551
  • Fax: 443-371-7667

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number47-1223781
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number47-1223781
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number47-1223781
License Number StateMD
# 4
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number47-1223781
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: