Healthcare Provider Details

I. General information

NPI: 1871661496
Provider Name (Legal Business Name): ANDREA LARISSA CERNEY LLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15370 LEVAN RD SUITE 2
LIVONIA MI
48154-1903
US

IV. Provider business mailing address

15151 SUNBURY ST
LIVONIA MI
48154-4058
US

V. Phone/Fax

Practice location:
  • Phone: 734-744-0170
  • Fax: 734-744-0171
Mailing address:
  • Phone: 248-640-9777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberL966260
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: