Healthcare Provider Details

I. General information

NPI: 1386433811
Provider Name (Legal Business Name): BENJAMIN LUKE LARISON MHC-LP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2025
Last Update Date: 05/01/2025
Certification Date: 05/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

579 COURTLANDT AVE
BRONX NY
10451-5013
US

IV. Provider business mailing address

413 E 114TH ST APT 4D
NEW YORK NY
10029-2330
US

V. Phone/Fax

Practice location:
  • Phone: 718-485-2100
  • Fax:
Mailing address:
  • Phone: 319-310-3432
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberP120899
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: