Healthcare Provider Details

I. General information

NPI: 1609599141
Provider Name (Legal Business Name): LARISSA WILLSEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2022
Last Update Date: 10/22/2025
Certification Date: 10/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1209 MOUNTAIN ROAD PL NE # 7464
ALBUQUERQUE NM
87110-7845
US

IV. Provider business mailing address

1209 MOUNTAIN ROAD PL NE # 7464
ALBUQUERQUE NM
87110-7845
US

V. Phone/Fax

Practice location:
  • Phone: 505-553-9069
  • Fax:
Mailing address:
  • Phone: 505-553-9069
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSWB-2022-0836
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: