Healthcare Provider Details

I. General information

NPI: 1831986538
Provider Name (Legal Business Name): LARISSA ROA-REYES LMSW
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2025
Last Update Date: 06/23/2025
Certification Date: 06/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 4TH AVE
BAY SHORE NY
11706-7908
US

IV. Provider business mailing address

21 4TH AVE
BAY SHORE NY
11706-7908
US

V. Phone/Fax

Practice location:
  • Phone: 631-665-6707
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number127466-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: